MEDICARE: ALICIA MICHELLE GREEN-FARRIS

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	363LP0808X	Psychiatric/Mental Health Nurse Practitioner	1010977	TX
2	363LP2300X	Primary Care Nurse Practitioner	1010977	TX

General Provider Information

NPI Number	:	1609340058
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ALICIA MICHELLE GREEN-FARRIS

Provider Business Mailing Address
First Line	:	1124 CANUELA WAY
Second Line	:
City	:	JUSTIN
State	:	TX
Zip	:	76247-1852
Country	:	US
Telephone Number	:	870-489-7220
Fax Number	:

Provider Business Practice Location Address
First Line	:	802 N BONNIE BRAE ST STE 108
Second Line	:
City	:	DENTON
State	:	TX
Zip	:	76201-2417
Country	:	US
Telephone Number	:	940-514-0133
Fax Number	:	940-514-0134

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

Provider Enumeration Date	:	01/18/2019
Last Update Date	:	02/13/2025

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