Provider Demographics
NPI:1811241292
Name:GREEN, MANDY (NP-C)
Entity type:Individual
Prefix:
First Name:MANDY
Middle Name:
Last Name:GREEN
Suffix:
Gender:
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 846098
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75284-6098
Mailing Address - Country:US
Mailing Address - Phone:903-324-6400
Mailing Address - Fax:
Practice Address - Street 1:910 E HOUSTON ST
Practice Address - Street 2:STE 230
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75702-8369
Practice Address - Country:US
Practice Address - Phone:903-525-7300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-11-06
Last Update Date:2025-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX679662363L00000X
TXAP122656363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX679662OtherTEXAS BOARD OF NURSING