Healthcare Provider Details

I. General information

NPI: 1063607810
Provider Name (Legal Business Name): ELAINE R GREEN NNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/13/2007
Last Update Date: 05/29/2025
Certification Date: 05/29/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3501 JOHNSON ST
HOLLYWOOD FL
33021-5421
US

IV. Provider business mailing address

1301 CONCORD TER
SUNRISE FL
33323-2843
US

V. Phone/Fax

Practice location:
  • Phone: 954-265-5830
  • Fax:
Mailing address:
  • Phone: 954-845-0405
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LN0005X
TaxonomyCritical Care Neonatal Nurse Practitioner
License NumberF350070
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number9338654
License Number StateFL
# 3
Primary TaxonomyY
Taxonomy Code363LN0000X
TaxonomyNeonatal Nurse Practitioner
License Number9338654
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: