Healthcare Provider Details

I. General information

NPI: 1467971416
Provider Name (Legal Business Name): ANGELA M GREENE PMHNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/11/2017
Last Update Date: 04/28/2021
Certification Date: 04/28/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3531 LAKELAND DR STE 1060
FLOWOOD MS
39232-8016
US

IV. Provider business mailing address

105 SPEERS VALLEY RD
BRANDON MS
39042-7549
US

V. Phone/Fax

Practice location:
  • Phone: 601-420-5810
  • Fax: 601-420-5811
Mailing address:
  • Phone: 601-906-7091
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberR866891
License Number StateMS
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberR866891
License Number StateMS
# 3
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberR866891
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: