Provider Demographics
NPI:1861761207
Name:GREEN, SHANA R (PMHNP-BC/ ANP-BC)
Entity type:Individual
Prefix:
First Name:SHANA
Middle Name:R
Last Name:GREEN
Suffix:
Gender:F
Credentials:PMHNP-BC/ ANP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1400 SW 5TH AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97201-5537
Mailing Address - Country:US
Mailing Address - Phone:503-418-3900
Mailing Address - Fax:503-418-3938
Practice Address - Street 1:3930 SE DIVISION ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97202-1643
Practice Address - Country:US
Practice Address - Phone:503-418-3900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-12-14
Last Update Date:2025-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA21009363LA2200X, 363LP0808X
COAPN.0993439-NP363LP0808X
OR201150173NP363LA2200X
CA708000163W00000X
CORN.1650946163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORR0000WCJHTMedicare Oscar/Certification
OR22959Medicaid