Provider Demographics
NPI:1982631040
Name:GREENE, SUSAN A (APRN-BC)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:A
Last Name:GREENE
Suffix:
Gender:F
Credentials:APRN-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1351 OLD MOBILE RD
Mailing Address - Street 2:
Mailing Address - City:MC CAYSVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30555-1950
Mailing Address - Country:US
Mailing Address - Phone:706-492-5274
Mailing Address - Fax:
Practice Address - Street 1:901 BOMBAY LN
Practice Address - Street 2:
Practice Address - City:ROSWELL
Practice Address - State:GA
Practice Address - Zip Code:30076-5829
Practice Address - Country:US
Practice Address - Phone:770-664-1920
Practice Address - Fax:888-388-9622
Is Sole Proprietor?:No
Enumeration Date:2006-06-26
Last Update Date:2011-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA100566363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA054554063AMedicaid
GA83-02313OtherEVERCARE
GA054554063AMedicaid
GA83-02313OtherEVERCARE