Healthcare Provider Details

I. General information

NPI: 1205443728
Provider Name (Legal Business Name): ASHLEY GREEN PA-C, RD, LD/N
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: ASHLEY HAMM

II. Dates (important events)

Enumeration Date: 09/29/2020
Last Update Date: 04/07/2025
Certification Date: 04/07/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1301 S INTERNATIONAL PKWY STE 1041
LAKE MARY FL
32746-1410
US

IV. Provider business mailing address

3675 SIMONTON PL
LAKE MARY FL
32746-6752
US

V. Phone/Fax

Practice location:
  • Phone: 407-732-7668
  • Fax:
Mailing address:
  • Phone: 772-834-7342
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA9113579
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberND7124
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: