Healthcare Provider Details

I. General information

NPI: 1124799176
Provider Name (Legal Business Name): CHANHOM L GREEN REGISTERED NURSE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/21/2021
Last Update Date: 09/21/2021
Certification Date: 09/14/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

555 WARREN RD
ITHACA NY
14850-1862
US

IV. Provider business mailing address

555 WARREN RD
ITHACA NY
14850-1862
US

V. Phone/Fax

Practice location:
  • Phone: 607-257-1555
  • Fax: 607-697-8220
Mailing address:
  • Phone: 607-257-1555
  • Fax: 607-257-1555

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WS0200X
TaxonomySchool Registered Nurse
License Number77531301
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: