Provider Demographics
NPI:1538555818
Name:GREEN, MICHELLE MARIE (APRN)
Entity type:Individual
Prefix:MS
First Name:MICHELLE
Middle Name:MARIE
Last Name:GREEN
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1267 N STEAMBOAT DR STE 3
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72704-7148
Mailing Address - Country:US
Mailing Address - Phone:479-316-6565
Mailing Address - Fax:479-316-0331
Practice Address - Street 1:1267 N STEAMBOAT DR STE 3
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:AR
Practice Address - Zip Code:72704-7148
Practice Address - Country:US
Practice Address - Phone:479-316-6565
Practice Address - Fax:479-316-0331
Is Sole Proprietor?:No
Enumeration Date:2015-04-13
Last Update Date:2021-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARA004383363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR208904758Medicaid