Basic Information
| Provider Information | |||||||||
| NPI: | 1205987047 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GREEN | ||||||||
| FirstName: | AMBER | ||||||||
| MiddleName: | STAR | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | APRN | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | PAWLIK | ||||||||
| OtherFirstName: | AMBER | ||||||||
| OtherMiddleName: | STAR | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1053 CENTER STREET | ||||||||
| Address2: | SC HOUSE CALLS INC | ||||||||
| City: | WEST COLUMBIA | ||||||||
| State: | SC | ||||||||
| PostalCode: | 29169 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8004910909 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1053 CENTER STREET | ||||||||
| Address2: | SC HOUSE CALLS INC | ||||||||
| City: | WEST COLUMBIA | ||||||||
| State: | SC | ||||||||
| PostalCode: | 29169 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8004910909 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/16/2007 | ||||||||
| LastUpdateDate: | 12/21/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 12/21/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | F333891 | NY | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363LF0000X | 7443 | TN | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363LF0000X | 3473 | SC | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 109194 | 01 | SC | SC RN MULTI-STATE LICENSE | OTHER | 111131 | 01 | TN | RN LICENSE # | OTHER | 3906732 | 01 | TN | XANTUS MEDICAID FOR TN | OTHER | 7443 | 01 | TN | APN LICENSE | OTHER | 4031021 | 01 | TN | BLUE CROSS BLUE SHIELD | OTHER | F333891-1 | 01 | NY | NURSE PRACTITIONER IN FAMILY HEALTH | OTHER | 533744-1 | 01 | NY | RN LICENSE | OTHER | F333891 | 01 | NY | FNP LICENSE # | OTHER | 3473 | 01 | SC | APRN FOR SC | OTHER | 533744 | 01 | NY | RN LICENSE # | OTHER |