Provider Demographics
NPI:1205434057
Name:GREEN, MICHELLE LEE (FNP)
Entity type:Individual
Prefix:MRS
First Name:MICHELLE
Middle Name:LEE
Last Name:GREEN
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2264 AN COUNTY ROAD 420
Mailing Address - Street 2:
Mailing Address - City:PALESTINE
Mailing Address - State:TX
Mailing Address - Zip Code:75803-6517
Mailing Address - Country:US
Mailing Address - Phone:805-503-8199
Mailing Address - Fax:
Practice Address - Street 1:2264 AN COUNTY ROAD 420
Practice Address - Street 2:
Practice Address - City:PALESTINE
Practice Address - State:TX
Practice Address - Zip Code:75803-6517
Practice Address - Country:US
Practice Address - Phone:805-503-8199
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-14
Last Update Date:2020-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP145854363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner