Healthcare Provider Details

I. General information

NPI: 1154872190
Provider Name (Legal Business Name): BIANCA GREEN NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: BIANCA ZDENEK

II. Dates (important events)

Enumeration Date: 10/14/2016
Last Update Date: 12/12/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5701 BOW POINTE DR
CLARKSTON MI
48346-3198
US

IV. Provider business mailing address

2561 ELIZABETH LAKE RD
WATERFORD MI
48328-3313
US

V. Phone/Fax

Practice location:
  • Phone: 248-625-2621
  • Fax: 248-625-2621
Mailing address:
  • Phone: 248-682-3300
  • Fax: 248-682-0026

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number4704292920
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: