1427355940 NPI number — HEATHER M GREEN ACNP

Table of content: HEATHER M GREEN ACNP (NPI 1427355940)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1427355940 NPI number — HEATHER M GREEN ACNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GREEN
Provider First Name:
HEATHER
Provider Middle Name:
M
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
ACNP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1427355940
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/31/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
121 PARK CENTRAL DR
Provider Second Line Business Mailing Address:
SUITE 200
Provider Business Mailing Address City Name:
COLUMBIA
Provider Business Mailing Address State Name:
SC
Provider Business Mailing Address Postal Code:
29203-6476
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
803-252-9907
Provider Business Mailing Address Fax Number:
803-252-9906

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
121 PARK CENTRAL DR
Provider Second Line Business Practice Location Address:
SUITE 200
Provider Business Practice Location Address City Name:
COLUMBIA
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29203-6476
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
803-252-9907
Provider Business Practice Location Address Fax Number:
803-252-9906
Provider Enumeration Date:
02/18/2011

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363LA2100X , with the licence number:  AC4454 , registered in the state of SC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: AC4454 . This is a "ACNP LICENSE" identifier , issued by the state of ( SC ) . This identifiers is of the category "OTHER".