=====================================================
General NPI Number Information
=====================================================
NPI Number | 1740225820
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LORI SHEA JEAN GREEN N.P.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/20/2006
-----------------------------------------------------
Last Update Date | 12/09/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 313 FEDERAL DR NW STE 130
-----------------------------------------------------
City | CORYDON
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 47112-3099
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 812-734-3952
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 330 SEVEN SPRINGS WAY
-----------------------------------------------------
City | BRENTWOOD
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37027-5098
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 615-920-7906
-----------------------------------------------------
Fax | 615-920-8938
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | 3005070
-----------------------------------------------------
License Number State | KY
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | 71000547A
-----------------------------------------------------
License Number State | IN
-----------------------------------------------------