Provider Demographics
NPI:1215127329
Name:GREEN, BECKY ANN (NP)
Entity type:Individual
Prefix:
First Name:BECKY
Middle Name:ANN
Last Name:GREEN
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10383 HIGHWAY 12
Mailing Address - Street 2:SUITE 116
Mailing Address - City:ORANGE
Mailing Address - State:TX
Mailing Address - Zip Code:77632-7415
Mailing Address - Country:US
Mailing Address - Phone:409-745-4130
Mailing Address - Fax:409-745-4187
Practice Address - Street 1:10383 HIGHWAY 12
Practice Address - Street 2:SUITE116
Practice Address - City:ORANGE
Practice Address - State:TX
Practice Address - Zip Code:77632-7415
Practice Address - Country:US
Practice Address - Phone:409-745-4130
Practice Address - Fax:409-745-4187
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-26
Last Update Date:2012-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXF0607267363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX30331101Medicaid
TXF0607267OtherNP-C
TXB148953Medicare PIN