=====================================================
General NPI Number Information
=====================================================
NPI Number | 1306542436
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JAN DENISE GREEN APRN
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/31/2023
-----------------------------------------------------
Last Update Date | 02/16/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5380 TECH DATA DR
-----------------------------------------------------
City | CLEARWATER
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33760-3122
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 272-850-8647
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 9021 143RD DR
-----------------------------------------------------
City | LIVE OAK
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32060-0300
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 386-249-9475
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | RN9355747
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | APRN11024413
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------