Healthcare Provider Details

I. General information

NPI: 1558708073
Provider Name (Legal Business Name): NICOLE ELISE GREENE ATC, LAT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/23/2013
Last Update Date: 01/07/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

211 EXECUTIVE DR SUITE 11
NEWARK DE
19702-3357
US

IV. Provider business mailing address

75 N FAIRFIELD DR
SMYRNA DE
19977-1516
US

V. Phone/Fax

Practice location:
  • Phone: 302-793-1800
  • Fax:
Mailing address:
  • Phone: 850-339-4369
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberAL3521
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: