Provider Demographics
NPI:1205992450
Name:GREEN-BLAIR, JEAN CAROLL (ARNP)
Entity type:Individual
Prefix:MRS
First Name:JEAN
Middle Name:CAROLL
Last Name:GREEN-BLAIR
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:MRS
Other - First Name:JEAN
Other - Middle Name:CAROLL
Other - Last Name:GREEN-BLAIR
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:ARNP
Mailing Address - Street 1:1100 LOVELAND BLVD
Mailing Address - Street 2:
Mailing Address - City:PORT CHARLOTTE
Mailing Address - State:FL
Mailing Address - Zip Code:33980-1802
Mailing Address - Country:US
Mailing Address - Phone:941-624-7200
Mailing Address - Fax:941-624-7202
Practice Address - Street 1:1100 LOVELAND BLVD
Practice Address - Street 2:
Practice Address - City:PORT CHARLOTTE
Practice Address - State:FL
Practice Address - Zip Code:33980-1802
Practice Address - Country:US
Practice Address - Phone:941-624-7200
Practice Address - Fax:941-624-7202
Is Sole Proprietor?:No
Enumeration Date:2006-12-29
Last Update Date:2013-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL3403762363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL306537500Medicaid
FLE4384WMedicare PIN