=====================================================
General NPI Number Information
=====================================================
NPI Number | 1750995270
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SHANNON MARIE GREEN MSN, FNP-C
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/02/2020
-----------------------------------------------------
Last Update Date | 02/24/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1701 E BROADWAY STE 302
-----------------------------------------------------
City | COLUMBIA
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 65201-8018
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 573-815-8277
-----------------------------------------------------
Fax | 573-815-8278
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1701 E BROADWAY STE 302
-----------------------------------------------------
City | COLUMBIA
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 65201-8018
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 573-815-8277
-----------------------------------------------------
Fax | 573-815-8278
-----------------------------------------------------
=====================================================
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 | 2020005249
-----------------------------------------------------
License Number State | MO
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363LA2200X
-----------------------------------------------------
Taxonomy Name | Adult Health Nurse Practitioner
-----------------------------------------------------
License Number | 2020005249
-----------------------------------------------------
License Number State | MO
-----------------------------------------------------