Healthcare Provider Details

I. General information

NPI: 1083604441
Provider Name (Legal Business Name): CONNIE GREEN CFNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/26/2005
Last Update Date: 09/26/2025
Certification Date: 09/26/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1902 HARPER RD STE ABC
BECKLEY WV
25801-2642
US

IV. Provider business mailing address

1902 HARPER RD STE ABC
BECKLEY WV
25801-2642
US

V. Phone/Fax

Practice location:
  • Phone: 304-253-3000
  • Fax: 304-929-2038
Mailing address:
  • Phone: 304-253-3000
  • Fax: 304-929-2038

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number34033
License Number StateWV
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number34033
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: