Provider Demographics
NPI:1336944750
Name:GREEN, TRICIALYN
Entity type:Individual
Prefix:
First Name:TRICIALYN
Middle Name:
Last Name:GREEN
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15731 COACH HOUSE CT NW
Mailing Address - Street 2:
Mailing Address - City:HARVEST
Mailing Address - State:AL
Mailing Address - Zip Code:35749-7861
Mailing Address - Country:US
Mailing Address - Phone:256-665-4172
Mailing Address - Fax:
Practice Address - Street 1:708 WILL HALSEY WAY
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:AL
Practice Address - Zip Code:35758-2565
Practice Address - Country:US
Practice Address - Phone:256-325-1349
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-02-18
Last Update Date:2025-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1-127637363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health