Provider Demographics
NPI:1245720705
Name:GREEN, STEPHANIE P (APN, FNP)
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:P
Last Name:GREEN
Suffix:
Gender:F
Credentials:APN, FNP
Other - Prefix:
Other - First Name:SKY
Other - Middle Name:P
Other - Last Name:GREEN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:FNP-C
Mailing Address - Street 1:611 W PARK ST
Mailing Address - Street 2:FAPC
Mailing Address - City:URBANA
Mailing Address - State:IL
Mailing Address - Zip Code:61801
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1801 W WINDSOR RD
Practice Address - Street 2:
Practice Address - City:CHAMPAIGN
Practice Address - State:IL
Practice Address - Zip Code:61822-6217
Practice Address - Country:US
Practice Address - Phone:217-366-8130
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-10
Last Update Date:2023-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209017535363L00000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL209017535Medicaid
ILMS5471230OtherDEA