Provider Demographics
NPI:1841374907
Name:GREEN, CYNTHIA (CACNP)
Entity type:Individual
Prefix:
First Name:CYNTHIA
Middle Name:
Last Name:GREEN
Suffix:
Gender:F
Credentials:CACNP
Other - Prefix:
Other - First Name:CYNTHIA
Other - Middle Name:
Other - Last Name:GREEN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:ACNP
Mailing Address - Street 1:1720A MEDICAL PARK DR
Mailing Address - Street 2:SUITE 340
Mailing Address - City:BILOXI
Mailing Address - State:MS
Mailing Address - Zip Code:39532-2129
Mailing Address - Country:US
Mailing Address - Phone:228-392-7429
Mailing Address - Fax:228-396-3830
Practice Address - Street 1:1720A MEDICAL PARK DR
Practice Address - Street 2:SUITE 340
Practice Address - City:BILOXI
Practice Address - State:MS
Practice Address - Zip Code:39532-2129
Practice Address - Country:US
Practice Address - Phone:228-392-7429
Practice Address - Fax:228-396-3830
Is Sole Proprietor?:No
Enumeration Date:2006-10-25
Last Update Date:2010-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR632333363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00126987Medicaid
MSP76263Medicare UPIN
MS00126987Medicaid