Provider Demographics
NPI:1932260627
Name:GREEN, JYLL K (ANP)
Entity Type:Individual
Prefix:
First Name:JYLL
Middle Name:K
Last Name:GREEN
Suffix:
Gender:F
Credentials:ANP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2105 E 88TH AVENUE
Mailing Address - Street 2:
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99507
Mailing Address - Country:US
Mailing Address - Phone:907-248-2482
Mailing Address - Fax:907-248-0045
Practice Address - Street 1:2105 E 88TH AVENUE
Practice Address - Street 2:
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99507
Practice Address - Country:US
Practice Address - Phone:907-248-2482
Practice Address - Fax:907-248-0045
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-13
Last Update Date:2013-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK859363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK1022671Medicaid
AKQ54761Medicare UPIN