MEDICARE: SUE ANN STANLEY-GREEN ATC

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	174400000X	Specialist	AL 1045	FL

General Provider Information

NPI Number	:	1487676615
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SUE ANN STANLEY-GREEN ATC

Provider Business Mailing Address
First Line	:	2504 CREWS LAKE HILLS LOOP N
Second Line	:
City	:	LAKELAND
State	:	FL
Zip	:	33813-3861
Country	:	US
Telephone Number	:	864-644-6878
Fax Number	:

Provider Business Practice Location Address
First Line	:	111 LAKE HOLLINGSWORTH DR
Second Line	:
City	:	LAKELAND
State	:	FL
Zip	:	33801-5607
Country	:	US
Telephone Number	:	864-680-4262
Fax Number	:

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

Provider Enumeration Date	:	07/24/2006
Last Update Date	:	07/08/2007

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