Provider Demographics
NPI:1306542436
Name:GREEN, JAN DENISE (APRN)
Entity type:Individual
Prefix:
First Name:JAN
Middle Name:DENISE
Last Name:GREEN
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9021 143RD DR
Mailing Address - Street 2:
Mailing Address - City:LIVE OAK
Mailing Address - State:FL
Mailing Address - Zip Code:32060-0300
Mailing Address - Country:US
Mailing Address - Phone:386-249-9475
Mailing Address - Fax:
Practice Address - Street 1:5380 TECH DATA DR
Practice Address - Street 2:
Practice Address - City:CLEARWATER
Practice Address - State:FL
Practice Address - Zip Code:33760-3122
Practice Address - Country:US
Practice Address - Phone:272-850-8647
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-01-31
Last Update Date:2023-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRN9355747363LF0000X
FLAPRN11024413363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily