Basic Information
| Provider Information | |||||||||
| NPI: | 1437121373 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GREEN | ||||||||
| FirstName: | ASHLEY | ||||||||
| MiddleName: | ELLEN | ||||||||
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| Credential: | APN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2809 FOREST HOME RD | ||||||||
| Address2: | |||||||||
| City: | JONESBORO | ||||||||
| State: | AR | ||||||||
| PostalCode: | 724015320 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8709721268 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1719 MERRILL DR | ||||||||
| Address2: | |||||||||
| City: | LITTLE ROCK | ||||||||
| State: | AR | ||||||||
| PostalCode: | 722124009 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5016632199 | ||||||||
| FaxNumber: | 5016632234 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/04/2006 | ||||||||
| LastUpdateDate: | 01/30/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/30/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LP0808X | A001912 | AR | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 199759758 | 05 | AR | MEDICAID |