Provider Demographics
NPI:1720475395
Name:GREEN, DESIRE D (NP)
Entity type:Individual
Prefix:
First Name:DESIRE
Middle Name:D
Last Name:GREEN
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:909 RIDGEBROOK RD STE 300
Mailing Address - Street 2:
Mailing Address - City:SPARKS GLENCOE
Mailing Address - State:MD
Mailing Address - Zip Code:21152-9477
Mailing Address - Country:US
Mailing Address - Phone:443-383-9300
Mailing Address - Fax:855-866-8710
Practice Address - Street 1:101 POTTERS LN
Practice Address - Street 2:
Practice Address - City:CLARKSVILLE
Practice Address - State:IN
Practice Address - Zip Code:47129-1000
Practice Address - Country:US
Practice Address - Phone:443-383-9300
Practice Address - Fax:855-866-8710
Is Sole Proprietor?:No
Enumeration Date:2015-04-22
Last Update Date:2022-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71005375A363L00000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201288380Medicaid
IN260690051Medicare PIN