Provider Demographics
NPI:1285086520
Name:GREEN, REBECCA J (APRN)
Entity type:Individual
Prefix:
First Name:REBECCA
Middle Name:J
Last Name:GREEN
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
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Mailing Address - Street 1:515 MEMORIAL DR
Mailing Address - Street 2:SUITE 3
Mailing Address - City:MANCHESTER
Mailing Address - State:KY
Mailing Address - Zip Code:40962-9157
Mailing Address - Country:US
Mailing Address - Phone:606-599-0169
Mailing Address - Fax:606-599-0297
Practice Address - Street 1:803 MEYERS BAKER RD STE 200
Practice Address - Street 2:
Practice Address - City:LONDON
Practice Address - State:KY
Practice Address - Zip Code:40741-3040
Practice Address - Country:US
Practice Address - Phone:606-878-3240
Practice Address - Fax:606-878-3245
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-11
Last Update Date:2022-03-31
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
KY3010388363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY3010388OtherKENTUCY LICENSE