Provider Demographics
NPI:1992283097
Name:GREENE, AVA DAWN (FNP-C)
Entity type:Individual
Prefix:
First Name:AVA
Middle Name:DAWN
Last Name:GREENE
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4705 TWO KNOTCH CIR
Mailing Address - Street 2:
Mailing Address - City:LAKE PARK
Mailing Address - State:GA
Mailing Address - Zip Code:31636-4981
Mailing Address - Country:US
Mailing Address - Phone:229-834-6453
Mailing Address - Fax:
Practice Address - Street 1:3003 VETERANS PKWY S
Practice Address - Street 2:
Practice Address - City:MOULTRIE
Practice Address - State:GA
Practice Address - Zip Code:31788-6705
Practice Address - Country:US
Practice Address - Phone:229-985-3422
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-31
Last Update Date:2018-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN118430363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily