Healthcare Provider Details

I. General information

NPI: 1578695045
Provider Name (Legal Business Name): NICOLE A GREEN MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/11/2007
Last Update Date: 10/23/2024
Certification Date: 10/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1600 ROCKLAND ROAD
WILMINGTON DE
19803-3607
US

IV. Provider business mailing address

P.O. BOX 191
ROCKLAND DE
19723-0191
US

V. Phone/Fax

Practice location:
  • Phone: 302-651-4000
  • Fax: 302-651-4945
Mailing address:
  • Phone: 302-651-4000
  • Fax: 302-651-4945

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207PP0204X
TaxonomyPediatric Emergency Medicine (Emergency Medicine) Physician
License NumberC10008651
License Number StateDE
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberC10008651
License Number StateDE
# 3
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License NumberC10008651
License Number StateDE
# 4
Primary TaxonomyY
Taxonomy Code2080P0204X
TaxonomyPediatric Emergency Medicine (Pediatrics) Physician
License NumberDR-0006401
License Number StateDE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: