Provider Demographics
NPI:1649075839
Name:GREEN, AMY ELLEN (CPHT-ADV)
Entity type:Individual
Prefix:
First Name:AMY
Middle Name:ELLEN
Last Name:GREEN
Suffix:
Gender:F
Credentials:CPHT-ADV
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3444 S SADLIER DR
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46239-1222
Mailing Address - Country:US
Mailing Address - Phone:317-667-3649
Mailing Address - Fax:
Practice Address - Street 1:8405 SOUTHEASTERN AVE
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46239-1348
Practice Address - Country:US
Practice Address - Phone:317-862-2414
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-02-13
Last Update Date:2025-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN67010078A183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician