Provider Demographics
NPI:1356896377
Name:GREEN, SHAWN (ACNS-BC, PMHNP-BC)
Entity type:Individual
Prefix:
First Name:SHAWN
Middle Name:
Last Name:GREEN
Suffix:
Gender:M
Credentials:ACNS-BC, PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2316 ECHELON LN
Mailing Address - Street 2:
Mailing Address - City:SMYRNA
Mailing Address - State:GA
Mailing Address - Zip Code:30080-2126
Mailing Address - Country:US
Mailing Address - Phone:404-435-9441
Mailing Address - Fax:
Practice Address - Street 1:1314 CONCORD RD SE
Practice Address - Street 2:
Practice Address - City:SMYRNA
Practice Address - State:GA
Practice Address - Zip Code:30080-4361
Practice Address - Country:US
Practice Address - Phone:770-438-1799
Practice Address - Fax:770-825-9046
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-19
Last Update Date:2024-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN16635364SA2200X, 363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Multi-Specialty
No364SA2200XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistAdult HealthGroup - Multi-Specialty