Provider Demographics
NPI:1902596539
Name:GREEN, RENITA ARTRICE (APRN)
Entity Type:Individual
Prefix:MS
First Name:RENITA
Middle Name:ARTRICE
Last Name:GREEN
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:MS
Other - First Name:RENITA
Other - Middle Name:
Other - Last Name:DYKES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:9635 WYDELLA ST
Mailing Address - Street 2:
Mailing Address - City:RIVERVIEW
Mailing Address - State:FL
Mailing Address - Zip Code:33569-9014
Mailing Address - Country:US
Mailing Address - Phone:727-331-9796
Mailing Address - Fax:
Practice Address - Street 1:2 TAMPA GENERAL CIR
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33606-3571
Practice Address - Country:US
Practice Address - Phone:813-821-8026
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-08
Last Update Date:2023-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN11026224367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLVVJ01OtherBCBS
FL118766300Medicaid