Healthcare Provider Details

I. General information

NPI: 1770404386
Provider Name (Legal Business Name): NANCY ANN GREEN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/22/2026
Last Update Date: 07/22/2026
Certification Date: 07/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15387 EDGEWATER RD NE
PINE CITY MN
55063-4784
US

IV. Provider business mailing address

15387 EDGEWATER RD NE
PINE CITY MN
55063-4784
US

V. Phone/Fax

Practice location:
  • Phone: 320-385-4477
  • Fax: 320-216-7638
Mailing address:
  • Phone: 320-385-4477
  • Fax: 320-216-7638

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172A00000X
TaxonomyDriver
License NumberS009199508309
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: