Healthcare Provider Details

I. General information

NPI: 1558330712
Provider Name (Legal Business Name): SHANNAN GREEN MD
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 03/17/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

140 W 11TH ST
FRONT ROYAL VA
22630-3512
US

IV. Provider business mailing address

140 W 11TH ST
FRONT ROYAL VA
22630-3512
US

V. Phone/Fax

Practice location:
  • Phone: 540-631-3700
  • Fax:
Mailing address:
  • Phone: 540-631-3700
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number0101238191
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: