Provider Demographics
NPI:1881671931
Name:GREEN, ANNIE B (FNP-BC)
Entity Type:Individual
Prefix:
First Name:ANNIE
Middle Name:B
Last Name:GREEN
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1729
Mailing Address - Street 2:
Mailing Address - City:HATTIESBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39403-1729
Mailing Address - Country:US
Mailing Address - Phone:601-545-3700
Mailing Address - Fax:601-450-2493
Practice Address - Street 1:66 OLD AIRPORT RD
Practice Address - Street 2:
Practice Address - City:HATTIESBURG
Practice Address - State:MS
Practice Address - Zip Code:39401-8382
Practice Address - Country:US
Practice Address - Phone:601-544-7500
Practice Address - Fax:601-544-7524
Is Sole Proprietor?:No
Enumeration Date:2005-12-29
Last Update Date:2014-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR733618363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS11582005OtherCAQH I D NUMBER
MS00123059Medicaid
MS00123059Medicaid
MS11582005OtherCAQH I D NUMBER