Healthcare Provider Details

I. General information

NPI: 1336711332
Provider Name (Legal Business Name): NOEL ILINE GREEN NNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/11/2021
Last Update Date: 07/11/2021
Certification Date: 07/11/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1919 E THOMAS RD
PHOENIX AZ
85016-7710
US

IV. Provider business mailing address

8742 CARPENTER RD
MONTGOMERY TX
77356-4205
US

V. Phone/Fax

Practice location:
  • Phone: 281-844-6283
  • Fax:
Mailing address:
  • Phone: 281-844-6283
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LN0005X
TaxonomyCritical Care Neonatal Nurse Practitioner
License Number1031690
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code363LN0005X
TaxonomyCritical Care Neonatal Nurse Practitioner
License Number259061
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: