Basic Information
| Provider Information | |||||||||
| NPI: | 1427705029 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GREEN | ||||||||
| FirstName: | JACQUELINE | ||||||||
| MiddleName: | ANES-QUANN | ||||||||
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| Credential: | AGPCNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 501 W 14TH ST | ||||||||
| Address2: | |||||||||
| City: | WILMINGTON | ||||||||
| State: | DE | ||||||||
| PostalCode: | 198011013 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3023204410 | ||||||||
| FaxNumber: | 3024284078 | ||||||||
| Practice Location | |||||||||
| Address1: | 501 W 14TH ST | ||||||||
| Address2: | |||||||||
| City: | WILMINGTON | ||||||||
| State: | DE | ||||||||
| PostalCode: | 198011013 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3023204410 | ||||||||
| FaxNumber: | 3024284078 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/04/2022 | ||||||||
| LastUpdateDate: | 03/07/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/07/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | L1-0048880 | DE | N | Nursing Service Providers | Registered Nurse | 363LG0600X | LP-0010505 | DE | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Gerontology | 363LA2200X | LP-0010505 | DE | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health |
No ID Information.