Provider Demographics
NPI:1861002099
Name:GREEN, ALYCIA MARIE
Entity Type:Individual
Prefix:
First Name:ALYCIA
Middle Name:MARIE
Last Name:GREEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:ALYCIA
Other - Middle Name:M
Other - Last Name:STREANDER; HINTON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 909
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40201-0909
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:908 DUPONT RD
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40207-4602
Practice Address - Country:US
Practice Address - Phone:502-749-7909
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-03
Last Update Date:2020-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY1104001163W00000X
KY3015106363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse