Healthcare Provider Details

I. General information

NPI: 1184978892
Provider Name (Legal Business Name): MARY CHRISTINE GREEN RN, PCNS-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: M CHRISTINE GREEN RN, PCNS-BC

II. Dates (important events)

Enumeration Date: 11/01/2012
Last Update Date: 11/01/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1465 S GRAND BLVD
SAINT LOUIS MO
63104-1003
US

IV. Provider business mailing address

1465 S GRAND BLVD
SAINT LOUIS MO
63104-1003
US

V. Phone/Fax

Practice location:
  • Phone: 314-577-5392
  • Fax: 314-268-6441
Mailing address:
  • Phone: 314-577-5392
  • Fax: 314-268-6441

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0200X
TaxonomyPediatric Registered Nurse
License Number079924
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: