Healthcare Provider Details

I. General information

NPI: 1760774772
Provider Name (Legal Business Name): LISA RENEE GREEN DNP, PMHNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/09/2011
Last Update Date: 03/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

90 GUARDIAN CT
ROCKY MOUNT NC
27804-3017
US

IV. Provider business mailing address

PO BOX 2723
ROCKY MOUNT NC
27802-2723
US

V. Phone/Fax

Practice location:
  • Phone: 252-212-3350
  • Fax: 252-212-0322
Mailing address:
  • Phone: 252-212-3486
  • Fax: 252-212-3497

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WP0200X
TaxonomyPediatric Registered Nurse
License NumberRN098822
License Number StateAZ
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number281796
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: