Healthcare Provider Details

I. General information

NPI: 1861761207
Provider Name (Legal Business Name): SHANA R GREEN PMHNP-BC/ ANP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/14/2011
Last Update Date: 03/11/2025
Certification Date: 03/11/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3930 SE DIVISION ST
PORTLAND OR
97202-1643
US

IV. Provider business mailing address

1400 SW 5TH AVE
PORTLAND OR
97201-5537
US

V. Phone/Fax

Practice location:
  • Phone: 503-418-3900
  • Fax:
Mailing address:
  • Phone: 503-418-3900
  • Fax: 503-418-3938

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number21009
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number21009
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberAPN.0993439-NP
License Number StateCO
# 4
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number201150173NP
License Number StateOR
# 5
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number708000
License Number StateCA
# 6
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN.1650946
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: