Healthcare Provider Details

I. General information

NPI: 1205059268
Provider Name (Legal Business Name): LUCILLE MONICA GREEN APN MSN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/10/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 LEXINGTON AVE
PASSAIC NJ
07055-5246
US

IV. Provider business mailing address

24 OAK ST
TEANECK NJ
07666-3827
US

V. Phone/Fax

Practice location:
  • Phone: 973-471-8006
  • Fax: 973-471-1630
Mailing address:
  • Phone: 201-836-1339
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0809X
TaxonomyAdult Psychiatric/Mental Health Registered Nurse
License Number26NC08138300
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: