Basic Information
| Provider Information | |||||||||
| NPI: | 1093715443 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GREEN | ||||||||
| FirstName: | ELIZABETH | ||||||||
| MiddleName: | JANE | ||||||||
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| Credential: | FNP-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2929 CALDER ST | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | BEAUMONT | ||||||||
| State: | TX | ||||||||
| PostalCode: | 777021845 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4098339797 | ||||||||
| FaxNumber: | 4096546886 | ||||||||
| Practice Location | |||||||||
| Address1: | 610 STRICKLAND DR | ||||||||
| Address2: | SUITE 140 | ||||||||
| City: | ORANGE | ||||||||
| State: | TX | ||||||||
| PostalCode: | 776304786 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4098339797 | ||||||||
| FaxNumber: | 4096546945 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/28/2005 | ||||||||
| LastUpdateDate: | 09/11/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 606373 | TX | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363LF0000X | AP113019 | TX | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 205564202 | 05 | TX | MEDICAID |