Provider Demographics
NPI:1801421300
Name:GREEN, STEPHANIE KEETON (AG ACNP)
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:KEETON
Last Name:GREEN
Suffix:
Gender:F
Credentials:AG ACNP
Other - Prefix:
Other - First Name:STEPHANIE
Other - Middle Name:N
Other - Last Name:KEETON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:221 W COLORADO BLVD
Mailing Address - Street 2:STE 525
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75208-2312
Mailing Address - Country:US
Mailing Address - Phone:214-960-5681
Mailing Address - Fax:
Practice Address - Street 1:221 W COLORADO BLVD STE 525
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75208-2312
Practice Address - Country:US
Practice Address - Phone:214-960-5681
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-05
Last Update Date:2022-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP145320363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care