Provider Demographics
NPI:1205443728
Name:GREEN, ASHLEY (PA-C, RD, LD/N)
Entity type:Individual
Prefix:
First Name:ASHLEY
Middle Name:
Last Name:GREEN
Suffix:
Gender:
Credentials:PA-C, RD, LD/N
Other - Prefix:
Other - First Name:ASHLEY
Other - Middle Name:
Other - Last Name:HAMM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3675 SIMONTON PL
Mailing Address - Street 2:
Mailing Address - City:LAKE MARY
Mailing Address - State:FL
Mailing Address - Zip Code:32746-6752
Mailing Address - Country:US
Mailing Address - Phone:772-834-7342
Mailing Address - Fax:
Practice Address - Street 1:1301 S INTERNATIONAL PKWY STE 1041
Practice Address - Street 2:
Practice Address - City:LAKE MARY
Practice Address - State:FL
Practice Address - Zip Code:32746-1410
Practice Address - Country:US
Practice Address - Phone:407-732-7668
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-29
Last Update Date:2025-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLND7124133V00000X
FLPA9113579363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No133V00000XDietary & Nutritional Service ProvidersDietitian, Registered