Healthcare Provider Details

I. General information

NPI: 1639513609
Provider Name (Legal Business Name): TAMMY S GREEN ANP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/22/2013
Last Update Date: 04/24/2023
Certification Date: 04/24/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

505 SYCAMORE ST
RISON AR
71665-7166
US

IV. Provider business mailing address

PO BOX 509
DERMOTT AR
71638-0509
US

V. Phone/Fax

Practice location:
  • Phone: 870-325-6255
  • Fax: 870-325-6117
Mailing address:
  • Phone: 870-538-5414
  • Fax: 870-538-5412

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberA003870
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: