Provider Demographics
NPI:1376504357
Name:GREEN, STEPHANIE L (CFNP)
Entity type:Individual
Prefix:MRS
First Name:STEPHANIE
Middle Name:L
Last Name:GREEN
Suffix:
Gender:F
Credentials:CFNP
Other - Prefix:
Other - First Name:STEPHANIE
Other - Middle Name:L
Other - Last Name:PEARCE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 397
Mailing Address - Street 2:
Mailing Address - City:BOARDMAN
Mailing Address - State:OR
Mailing Address - Zip Code:97818-0397
Mailing Address - Country:US
Mailing Address - Phone:541-481-7212
Mailing Address - Fax:541-481-5447
Practice Address - Street 1:450 TATONE ST
Practice Address - Street 2:
Practice Address - City:BOARDMAN
Practice Address - State:OR
Practice Address - Zip Code:97818-8076
Practice Address - Country:US
Practice Address - Phone:541-481-7212
Practice Address - Fax:541-481-2020
Is Sole Proprietor?:No
Enumeration Date:2006-03-30
Last Update Date:2025-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS804976363L00000X
COAPN.0992934-NP363LF0000X
NE2066363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS07358266Medicaid