Provider Demographics
NPI:1902369671
Name:GREEN, JAMES D (FNP)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:D
Last Name:GREEN
Suffix:
Gender:M
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1216 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:FESTUS
Mailing Address - State:MO
Mailing Address - Zip Code:63028-1654
Mailing Address - Country:US
Mailing Address - Phone:636-543-7600
Mailing Address - Fax:
Practice Address - Street 1:1216 W MAIN ST
Practice Address - Street 2:
Practice Address - City:FESTUS
Practice Address - State:MO
Practice Address - Zip Code:63028-1654
Practice Address - Country:US
Practice Address - Phone:636-543-7600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-10
Last Update Date:2021-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS53-78679-061363LF0000X
MO2021035759363LF0000X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS53-78679-061OtherKANSAS LICENSE NUMBER