Healthcare Provider Details

I. General information

NPI: 1427705029
Provider Name (Legal Business Name): JACQUELINE ANES-QUANN GREEN AGPCNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/04/2022
Last Update Date: 03/07/2022
Certification Date: 03/07/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

501 W 14TH ST
WILMINGTON DE
19801-1013
US

IV. Provider business mailing address

501 W 14TH ST
WILMINGTON DE
19801-1013
US

V. Phone/Fax

Practice location:
  • Phone: 302-320-4410
  • Fax: 302-428-4078
Mailing address:
  • Phone: 302-320-4410
  • Fax: 302-428-4078

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberL1-0048880
License Number StateDE
# 2
Primary TaxonomyN
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License NumberLP-0010505
License Number StateDE
# 3
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberLP-0010505
License Number StateDE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: