Provider Demographics
NPI:1992420418
Name:GREEN, GINA LYNNE (FNP-C)
Entity type:Individual
Prefix:
First Name:GINA
Middle Name:LYNNE
Last Name:GREEN
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 1:15600 PORTAGE RD
Mailing Address - Street 2:
Mailing Address - City:VICKSBURG
Mailing Address - State:MI
Mailing Address - Zip Code:49097-9722
Mailing Address - Country:US
Mailing Address - Phone:269-718-7733
Mailing Address - Fax:
Practice Address - Street 1:15600 PORTAGE RD
Practice Address - Street 2:
Practice Address - City:VICKSBURG
Practice Address - State:MI
Practice Address - Zip Code:49097-9722
Practice Address - Country:US
Practice Address - Phone:269-718-7733
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-10-06
Last Update Date:2023-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704258294363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily