Healthcare Provider Details

I. General information

NPI: 1124352984
Provider Name (Legal Business Name): JENNIFER GREEN LPN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/28/2009
Last Update Date: 09/28/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5226 COUNTY ROAD 1
RUSHVILLE NY
14544-9724
US

IV. Provider business mailing address

5226 COUNTY ROAD 1
RUSHVILLE NY
14544-9724
US

V. Phone/Fax

Practice location:
  • Phone: 585-554-4623
  • Fax:
Mailing address:
  • Phone: 585-554-4623
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License Number266456-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: