Basic Information
| Provider Information | |||||||||
| NPI: | 1649543752 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GREEN | ||||||||
| FirstName: | SUNNY | ||||||||
| MiddleName: | GHERE | ||||||||
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| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1702 N BURNSIDE AVE | ||||||||
| Address2: | |||||||||
| City: | GONZALES | ||||||||
| State: | LA | ||||||||
| PostalCode: | 707372141 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2256478319 | ||||||||
| FaxNumber: | 2256445213 | ||||||||
| Practice Location | |||||||||
| Address1: | 1702 N BURNSIDE AVE | ||||||||
| Address2: | |||||||||
| City: | GONZALES | ||||||||
| State: | LA | ||||||||
| PostalCode: | 707372141 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2256478319 | ||||||||
| FaxNumber: | 2256445213 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/21/2012 | ||||||||
| LastUpdateDate: | 04/16/2013 | ||||||||
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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 | AP06727 | LA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 2181319 | 05 | LA | MEDICAID |