Provider Demographics
NPI:1992772073
Name:GREEN, SHANNON (APRN)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:GREEN
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2 INNOVATION DRIVE
Mailing Address - Street 2:SUITE 140
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29607-5263
Mailing Address - Country:US
Mailing Address - Phone:864-295-1750
Mailing Address - Fax:864-295-1753
Practice Address - Street 1:2 INNOVATION DRIVE
Practice Address - Street 2:SUITE 140
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29605-5263
Practice Address - Country:US
Practice Address - Phone:864-295-1750
Practice Address - Fax:864-295-1753
Is Sole Proprietor?:No
Enumeration Date:2006-03-07
Last Update Date:2011-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC2699363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCQ70136Medicare UPIN
SCAA13773968Medicare PIN