Provider Demographics
NPI:1609340058
Name:GREEN-FARRIS, ALICIA MICHELLE
Entity type:Individual
Prefix:
First Name:ALICIA
Middle Name:MICHELLE
Last Name:GREEN-FARRIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:ALICIA
Other - Middle Name:MICHELLE
Other - Last Name:GREEN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1124 CANUELA WAY
Mailing Address - Street 2:
Mailing Address - City:JUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:76247-1852
Mailing Address - Country:US
Mailing Address - Phone:870-489-7220
Mailing Address - Fax:
Practice Address - Street 1:802 N BONNIE BRAE ST STE 108
Practice Address - Street 2:
Practice Address - City:DENTON
Practice Address - State:TX
Practice Address - Zip Code:76201-2417
Practice Address - Country:US
Practice Address - Phone:940-514-0133
Practice Address - Fax:940-514-0134
Is Sole Proprietor?:No
Enumeration Date:2019-01-18
Last Update Date:2025-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1010977363LP0808X, 363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
No363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health