Provider Demographics
NPI:1134080922
Name:GREEN, LA SHANNON
Entity type:Individual
Prefix:
First Name:LA SHANNON
Middle Name:
Last Name:GREEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4009 AVION DR
Mailing Address - Street 2:
Mailing Address - City:SANGER
Mailing Address - State:TX
Mailing Address - Zip Code:76266-1726
Mailing Address - Country:US
Mailing Address - Phone:469-989-6472
Mailing Address - Fax:469-989-6472
Practice Address - Street 1:4009 AVION DR
Practice Address - Street 2:
Practice Address - City:SANGER
Practice Address - State:TX
Practice Address - Zip Code:76266-1726
Practice Address - Country:US
Practice Address - Phone:469-989-6472
Practice Address - Fax:469-989-6472
Is Sole Proprietor?:No
Enumeration Date:2025-11-20
Last Update Date:2025-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1195392363LP2300X, 363LA2200X, 363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology