Healthcare Provider Details

I. General information

NPI: 1790351427
Provider Name (Legal Business Name): CLAUDETTE A GREEN NP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/02/2021
Last Update Date: 09/14/2023
Certification Date: 09/14/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 CLYBURN PL
AIKEN SC
29801-4193
US

IV. Provider business mailing address

3536 DANIEL PLACE DR
CHARLOTTE NC
28213-4817
US

V. Phone/Fax

Practice location:
  • Phone: 803-380-7000
  • Fax:
Mailing address:
  • Phone: 704-778-8136
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WM0705X
TaxonomyMedical-Surgical Registered Nurse
License Number221763
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberGREE-159Z3
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: