Provider Demographics
NPI:1669692356
Name:GREEN, STEPHANIE NOLAN (PA)
Entity type:Individual
Prefix:MRS
First Name:STEPHANIE
Middle Name:NOLAN
Last Name:GREEN
Suffix:
Gender:F
Credentials:PA
Other - Prefix:MS
Other - First Name:STEPHANIE
Other - Middle Name:MAUREEN
Other - Last Name:NOLAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:174 CHESTER AVE SE UNIT 57
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30316-1294
Mailing Address - Country:US
Mailing Address - Phone:404-791-2008
Mailing Address - Fax:
Practice Address - Street 1:35 JESSE HILL JR DR SE
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30303-3032
Practice Address - Country:US
Practice Address - Phone:404-791-2008
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-26
Last Update Date:2015-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA005029363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant