Healthcare Provider Details

I. General information

NPI: 1740225820
Provider Name (Legal Business Name): LORI SHEA JEAN GREEN N.P.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/20/2006
Last Update Date: 12/09/2020
Certification Date: 12/09/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

313 FEDERAL DR NW STE 130
CORYDON IN
47112-3099
US

IV. Provider business mailing address

330 SEVEN SPRINGS WAY
BRENTWOOD TN
37027-5098
US

V. Phone/Fax

Practice location:
  • Phone: 812-734-3952
  • Fax:
Mailing address:
  • Phone: 615-920-7906
  • Fax: 615-920-8938

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number3005070
License Number StateKY
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number71000547A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: