Healthcare Provider Details

I. General information

NPI: 1568026011
Provider Name (Legal Business Name): CAROL GAYE GREEN FAMILY NURSE PRACTIT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/30/2019
Last Update Date: 07/17/2026
Certification Date: 07/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2100 N MAIN ST STE 304
CROWN POINT IN
46307-1877
US

IV. Provider business mailing address

2100 N MAIN ST STE 304
CROWN POINT IN
46307-1877
US

V. Phone/Fax

Practice location:
  • Phone: 574-546-1900
  • Fax: 574-546-1999
Mailing address:
  • Phone: 574-546-1900
  • Fax: 574-546-1999

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberSP034863
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number34108
License Number StateTN
# 3
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number4704385483
License Number StateMI
# 4
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number1118586
License Number StateTX
# 5
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number3013949
License Number StateKY
# 6
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number71009354A
License Number StateIN
# 7
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number71009354A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: