Healthcare Provider Details

I. General information

NPI: 1497351274
Provider Name (Legal Business Name): MRS. SAMANTHA MARIE GREEN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/08/2020
Last Update Date: 07/24/2024
Certification Date: 07/24/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1005 HARBORSIDE DR
GALVESTON TX
77555-1505
US

IV. Provider business mailing address

PO BOX 650859 DEPT 710
DALLAS TX
75265
US

V. Phone/Fax

Practice location:
  • Phone: 409-772-9507
  • Fax:
Mailing address:
  • Phone: 409-747-6240
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number1034158
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: