MEDICARE: LILLIE RUTH GREEN

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	363LF0000X	Family Nurse Practitioner	APRN11007976	FL
2	363LP0808X	Psychiatric/Mental Health Nurse Practitioner	GAA-NP004941	GA

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	:	1205435641
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LILLIE RUTH GREEN

Provider Business Mailing Address
First Line	:	1317 BLOSSOM CIR
Second Line	:
City	:	TALLAHASSEE
State	:	FL
Zip	:	32305-6707
Country	:	US
Telephone Number	:	229-726-3984
Fax Number	:

Provider Business Practice Location Address
First Line	:	278 LASALLE LEFALL DR
Second Line	:
City	:	QUINCY
State	:	FL
Zip	:	32351-5324
Country	:	US
Telephone Number	:	229-726-3984
Fax Number	:

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

Provider Enumeration Date	:	10/17/2020
Last Update Date	:	05/11/2026

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Directions to “ LILLIE RUTH GREEN ” Practice Location

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