Basic Information
| Provider Information | |||||||||
| NPI: | 1376504357 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GREEN | ||||||||
| FirstName: | STEPHANIE | ||||||||
| MiddleName: | L | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | CFNP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | PEARCE | ||||||||
| OtherFirstName: | STEPHANIE | ||||||||
| OtherMiddleName: | L | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1000 POLE CREEK XING STE 1 | ||||||||
| Address2: | |||||||||
| City: | SIDNEY | ||||||||
| State: | NE | ||||||||
| PostalCode: | 691622902 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3082545544 | ||||||||
| FaxNumber: | 3082542672 | ||||||||
| Practice Location | |||||||||
| Address1: | 1000 POLE CREEK XING STE 1 | ||||||||
| Address2: | |||||||||
| City: | SIDNEY | ||||||||
| State: | NE | ||||||||
| PostalCode: | 69162 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3082545544 | ||||||||
| FaxNumber: | 3082542672 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/30/2006 | ||||||||
| LastUpdateDate: | 06/05/2018 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 804976 | MS | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363LF0000X | APN.0992934-NP | CO | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363LF0000X | 2066 | NE | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 07358266 | 05 | MS | MEDICAID |