Provider Demographics
NPI:1306348487
Name:GREEN, JACQUELINE PRISCILLA (CRNP)
Entity type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:PRISCILLA
Last Name:GREEN
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 ELKO JCT
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:AL
Mailing Address - Zip Code:35758-3628
Mailing Address - Country:US
Mailing Address - Phone:864-706-5829
Mailing Address - Fax:
Practice Address - Street 1:717 PRATT AVE NE
Practice Address - Street 2:
Practice Address - City:HUNTSVILLE
Practice Address - State:AL
Practice Address - Zip Code:35801-3645
Practice Address - Country:US
Practice Address - Phone:256-808-2273
Practice Address - Fax:256-808-2274
Is Sole Proprietor?:No
Enumeration Date:2018-03-05
Last Update Date:2018-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1-158039363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL1-158039OtherAL NP LICENSE NUMBER