Provider Demographics
NPI:1871109017
Name:GREEN, STEPHANIE (FNP)
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:
Last Name:GREEN
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:286 S LENZNER AVE
Mailing Address - Street 2:
Mailing Address - City:SIERRA VISTA
Mailing Address - State:AZ
Mailing Address - Zip Code:85635-5685
Mailing Address - Country:US
Mailing Address - Phone:520-452-0388
Mailing Address - Fax:877-281-8622
Practice Address - Street 1:3908 10TH ST SE
Practice Address - Street 2:
Practice Address - City:PUYALLUP
Practice Address - State:WA
Practice Address - Zip Code:98374-2188
Practice Address - Country:US
Practice Address - Phone:253-848-5951
Practice Address - Fax:253-845-7073
Is Sole Proprietor?:No
Enumeration Date:2020-09-22
Last Update Date:2024-09-10
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
WAAP61132596363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner