Provider Demographics
NPI:1144258989
Name:GREEN, MELISSA (CRNA)
Entity type:Individual
Prefix:
First Name:MELISSA
Middle Name:
Last Name:GREEN
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:MELISSA
Other - Middle Name:
Other - Last Name:KEMPER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:5080 MOGOLLON RIM DR
Mailing Address - Street 2:
Mailing Address - City:LAKESIDE
Mailing Address - State:AZ
Mailing Address - Zip Code:85929-5530
Mailing Address - Country:US
Mailing Address - Phone:480-297-5926
Mailing Address - Fax:
Practice Address - Street 1:5080 MOGOLLON RIM DR
Practice Address - Street 2:
Practice Address - City:LAKESIDE
Practice Address - State:AZ
Practice Address - Zip Code:85929-5530
Practice Address - Country:US
Practice Address - Phone:480-297-5926
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-29
Last Update Date:2011-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZRN156511367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZ142693OtherMEDICARE PROVIDER
IN200513500Medicaid