Healthcare Provider Details

I. General information

NPI: 1083993661
Provider Name (Legal Business Name): SUE A GREEN FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/12/2011
Last Update Date: 08/12/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

369 E MAIN ST
WATERLOO NY
13165-1654
US

IV. Provider business mailing address

35 MASON ST SUITE 214
GENEVA NY
14456-1133
US

V. Phone/Fax

Practice location:
  • Phone: 315-539-4025
  • Fax:
Mailing address:
  • Phone: 315-230-5646
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberF336853
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: