MEDICARE: DONNIELLE LYNN GREEN DO

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207R00000X	Internal Medicine Physician	894	SC
2	207R00000X	Internal Medicine Physician	2012-01587	NC

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1073620530
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DONNIELLE LYNN GREEN DO

Provider Business Mailing Address
First Line	:	PO BOX 470408
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28247-0408
Country	:	US
Telephone Number	:	704-375-0100
Fax Number	:

Provider Business Practice Location Address
First Line	:	951 WENDOVER HEIGHT DR
Second Line	:
City	:	SHELBY
State	:	NC
Zip	:	28150-3565
Country	:	US
Telephone Number	:	704-487-4677
Fax Number	:	704-887-6450

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/23/2006
Last Update Date	:	09/05/2025

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