Basic Information
| Provider Information | |||||||||
| NPI: | 1003105610 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GREEN | ||||||||
| FirstName: | MERRY LYN | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | ANP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 40 S MAIN ST STE 1300 | ||||||||
| Address2: | |||||||||
| City: | MEMPHIS | ||||||||
| State: | TN | ||||||||
| PostalCode: | 381035513 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6694901088 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 845 3RD AVE FL 6 | ||||||||
| Address2: | |||||||||
| City: | NEW YORK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 100226630 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8669490108 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/04/2011 | ||||||||
| LastUpdateDate: | 04/28/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/28/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LA2200X | F305656-1 | NY | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health |
ID Information
| ID | Type | State | Issuer | Description | 03552090 | 05 | NY | MEDICAID |