Basic Information
| Provider Information | |||||||||
| NPI: | 1134774045 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GREEN | ||||||||
| FirstName: | ANGELA-THERESA | ||||||||
| MiddleName: | C | ||||||||
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| Credential: | APRN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1839 CENTRAL AVE | ||||||||
| Address2: | |||||||||
| City: | ST PETERSBURG | ||||||||
| State: | FL | ||||||||
| PostalCode: | 337138900 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7278201040 | ||||||||
| FaxNumber: | 7278217213 | ||||||||
| Practice Location | |||||||||
| Address1: | 300 PINELLAS ST | ||||||||
| Address2: | |||||||||
| City: | CLEARWATER | ||||||||
| State: | FL | ||||||||
| PostalCode: | 337563804 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7274627000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/07/2019 | ||||||||
| LastUpdateDate: | 11/06/2019 | ||||||||
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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 | 363LP2300X | 11003635 | FL | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Primary Care | 363LA2200X | 11003635 | FL | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health |
No ID Information.