Provider Demographics
NPI:1124528237
Name:GREEN, STEPHANIE NICOLE (FNP-C)
Entity type:Individual
Prefix:MRS
First Name:STEPHANIE
Middle Name:NICOLE
Last Name:GREEN
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3172 PAXTON RD
Mailing Address - Street 2:
Mailing Address - City:FOLKSTON
Mailing Address - State:GA
Mailing Address - Zip Code:31537-9079
Mailing Address - Country:US
Mailing Address - Phone:912-276-0562
Mailing Address - Fax:
Practice Address - Street 1:2060 DAN PROCTOR DR STE 2100
Practice Address - Street 2:
Practice Address - City:SAINT MARYS
Practice Address - State:GA
Practice Address - Zip Code:31558-3895
Practice Address - Country:US
Practice Address - Phone:912-882-6767
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-15
Last Update Date:2018-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN231333363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care