Provider Demographics
NPI:1649543752
Name:GREEN, SUNNY GHERE (NP)
Entity type:Individual
Prefix:
First Name:SUNNY
Middle Name:GHERE
Last Name:GREEN
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1702 N BURNSIDE AVE
Mailing Address - Street 2:
Mailing Address - City:GONZALES
Mailing Address - State:LA
Mailing Address - Zip Code:70737-2141
Mailing Address - Country:US
Mailing Address - Phone:225-647-8319
Mailing Address - Fax:225-644-5213
Practice Address - Street 1:1702 N BURNSIDE AVE
Practice Address - Street 2:
Practice Address - City:GONZALES
Practice Address - State:LA
Practice Address - Zip Code:70737-2141
Practice Address - Country:US
Practice Address - Phone:225-647-8319
Practice Address - Fax:225-644-5213
Is Sole Proprietor?:No
Enumeration Date:2012-02-21
Last Update Date:2013-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAAP06727363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2181319Medicaid
LA254947YJFFMedicare PIN