Provider Demographics
NPI:1720464597
Name:GREEN, PAMELA (NURSE)
Entity Type:Individual
Prefix:
First Name:PAMELA
Middle Name:
Last Name:GREEN
Suffix:
Gender:F
Credentials:NURSE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:574 WINDSOR DR
Mailing Address - Street 2:
Mailing Address - City:FOREST PARK
Mailing Address - State:GA
Mailing Address - Zip Code:30297-2912
Mailing Address - Country:US
Mailing Address - Phone:404-396-3096
Mailing Address - Fax:
Practice Address - Street 1:574 WINDSOR DR
Practice Address - Street 2:
Practice Address - City:FOREST PARK
Practice Address - State:GA
Practice Address - Zip Code:30297-2912
Practice Address - Country:US
Practice Address - Phone:404-396-3096
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-08-04
Last Update Date:2015-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN224259163WH0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WH0200XNursing Service ProvidersRegistered NurseHome Health