Healthcare Provider Details

I. General information

NPI: 1285193441
Provider Name (Legal Business Name): CARRIE ANNE GREEN APN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: CARRIE ANNE CROSS APN

II. Dates (important events)

Enumeration Date: 03/18/2019
Last Update Date: 12/03/2024
Certification Date: 12/03/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 W HARLEM AVE
MONMOUTH IL
61462-1007
US

IV. Provider business mailing address

1000 W HARLEM AVE
MONMOUTH IL
61462-1007
US

V. Phone/Fax

Practice location:
  • Phone: 309-734-1414
  • Fax: 309-734-0323
Mailing address:
  • Phone: 309-734-1414
  • Fax: 309-734-0323

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number209019054
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: