Basic Information
| Provider Information | |||||||||
| NPI: | 1578877148 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GREEN | ||||||||
| FirstName: | JANICE | ||||||||
| MiddleName: | LYNN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7471 N FRESNO ST | ||||||||
| Address2: | |||||||||
| City: | FRESNO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 937202457 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5594364500 | ||||||||
| FaxNumber: | 5592611526 | ||||||||
| Practice Location | |||||||||
| Address1: | 7471 N FRESNO ST | ||||||||
| Address2: | |||||||||
| City: | FRESNO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 937202457 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5594364500 | ||||||||
| FaxNumber: | 5592611526 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/05/2010 | ||||||||
| LastUpdateDate: | 08/15/2011 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LP0200X | 602733 | CA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | GR0043790 | 01 | CA | MEDICAL ID FOR BAZ ALLERGY, ASTHM & SINUS CENTER | OTHER | ZZZ21572Z | 01 | CA | GROUP PTAN FOR BAZ ALLERGY,ASTHMA & SINUS CENTER | OTHER |