Provider Demographics
NPI:1992769897
Name:GREEN, G. LYNN (APNP)
Entity type:Individual
Prefix:
First Name:G.
Middle Name:LYNN
Last Name:GREEN
Suffix:
Gender:F
Credentials:APNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:825 CHALLENGER DR
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54311-8328
Mailing Address - Country:US
Mailing Address - Phone:920-469-1313
Mailing Address - Fax:920-469-4428
Practice Address - Street 1:825 CHALLENGER DR
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54311-8328
Practice Address - Country:US
Practice Address - Phone:920-469-1313
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-17
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1221-033363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI43908300Medicaid
WIMG0358158OtherDEA #
WIS73960Medicare UPIN