Provider Demographics
NPI:1245536697
Name:GREEN, MICHELLE GAIL (FNP)
Entity type:Individual
Prefix:MS
First Name:MICHELLE
Middle Name:GAIL
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 1:3210 N ANDREWS AVENUE EXT
Mailing Address - Street 2:
Mailing Address - City:POMPANO BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33064-2116
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:561-516-7362
Practice Address - Street 1:10970 CROSS CREEK BLVD
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33647-4055
Practice Address - Country:US
Practice Address - Phone:866-550-2212
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-02-02
Last Update Date:2024-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR121608363LF0000X
FLAPRN9422087363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
802582YZB6Medicare UPIN