Provider Demographics
NPI:1982057345
Name:GREEN, FLORA K (AGPCNP)
Entity Type:Individual
Prefix:
First Name:FLORA
Middle Name:K
Last Name:GREEN
Suffix:
Gender:F
Credentials:AGPCNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:350 W WOODROW WILSON AVE
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39213-7681
Mailing Address - Country:US
Mailing Address - Phone:601-709-5130
Mailing Address - Fax:
Practice Address - Street 1:350 W WOODROW WILSON AVE
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39213-7681
Practice Address - Country:US
Practice Address - Phone:601-709-5130
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-07-20
Last Update Date:2017-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR812386363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology