Healthcare Provider Details

I. General information

NPI: 1275180200
Provider Name (Legal Business Name): JANISH LEE GREEN FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/23/2019
Last Update Date: 03/07/2023
Certification Date: 05/04/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10701 INTERNATIONAL DR
ORLANDO FL
32821-7392
US

IV. Provider business mailing address

10701 INTERNATIONAL DR
ORLANDO FL
32821-7392
US

V. Phone/Fax

Practice location:
  • Phone: 407-355-0929
  • Fax:
Mailing address:
  • Phone: 407-355-0929
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAPRN11011986
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number0024178370
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: