Healthcare Provider Details

I. General information

NPI: 1942622915
Provider Name (Legal Business Name): TIFFINY SHANTAY GREEN APN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/10/2014
Last Update Date: 03/05/2025
Certification Date: 03/05/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

417 WARREN ST UNIT 373
BEVERLY NJ
08010-1100
US

IV. Provider business mailing address

417 WARREN ST UNIT 373
BEVERLY NJ
08010-1100
US

V. Phone/Fax

Practice location:
  • Phone: 609-227-1970
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number26NR15665200
License Number StateNJ
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number26NJ00685600
License Number StateNJ
# 3
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number2023061499
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: