Provider Demographics
NPI:1699318303
Name:GREEN, GREGORY ALLEN (NP)
Entity type:Individual
Prefix:
First Name:GREGORY
Middle Name:ALLEN
Last Name:GREEN
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2246 ROCKY FACE CIR
Mailing Address - Street 2:
Mailing Address - City:DALTON
Mailing Address - State:GA
Mailing Address - Zip Code:30720-2946
Mailing Address - Country:US
Mailing Address - Phone:706-313-6033
Mailing Address - Fax:
Practice Address - Street 1:2246 ROCKY FACE CIR
Practice Address - Street 2:
Practice Address - City:DALTON
Practice Address - State:GA
Practice Address - Zip Code:30720-2946
Practice Address - Country:US
Practice Address - Phone:706-313-6033
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-25
Last Update Date:2019-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN114145363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily