Healthcare Provider Details

I. General information

NPI: 1902711161
Provider Name (Legal Business Name): CHANTEL GREEN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/14/2026
Last Update Date: 08/14/2026
Certification Date: 08/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21 GARDNER ST
NEWBURGH NY
12550-3114
US

IV. Provider business mailing address

21 GARDNER ST
NEWBURGH NY
12550-3114
US

V. Phone/Fax

Practice location:
  • Phone: 845-874-3049
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License Number357570
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: