Basic Information
| Provider Information | |||||||||
| NPI: | 1487683074 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GREEN | ||||||||
| FirstName: | SPARKLE | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | ARNP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | GREEN | ||||||||
| OtherFirstName: | GOLDIE | ||||||||
| OtherMiddleName: | SPARKLE | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | ARNP | ||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | 911 S MAIN ST | ||||||||
| Address2: | |||||||||
| City: | TRENTON | ||||||||
| State: | FL | ||||||||
| PostalCode: | 326933239 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3524632374 | ||||||||
| FaxNumber: | 3524632726 | ||||||||
| Practice Location | |||||||||
| Address1: | 173 NW ALBRITTON LN | ||||||||
| Address2: | |||||||||
| City: | LAKE CITY | ||||||||
| State: | FL | ||||||||
| PostalCode: | 320554451 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3867554020 | ||||||||
| FaxNumber: | 3867529143 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/03/2006 | ||||||||
| LastUpdateDate: | 03/19/2014 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 1181972 | FL | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 033364600 | 05 | FL | MEDICAID | 1181972 | 01 | FL | FLORIDA LICENSE NUMBER | OTHER |