Healthcare Provider Details

I. General information

NPI: 1598413304
Provider Name (Legal Business Name): SIERRA N GREEN PMHNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/11/2022
Last Update Date: 06/09/2022
Certification Date: 06/09/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 MACARTHUR BLVD STE 5
MUNSTER IN
46321-2917
US

IV. Provider business mailing address

8558 BROADWAY
MERRILLVILLE IN
46410-7032
US

V. Phone/Fax

Practice location:
  • Phone: 219-392-7025
  • Fax: 219-392-7026
Mailing address:
  • Phone: 193-927-0842
  • Fax: 219-703-6854

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number71012595A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: