Healthcare Provider Details

I. General information

NPI: 1164676821
Provider Name (Legal Business Name): UTHONA RENEE GREEN CNS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/07/2008
Last Update Date: 11/07/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4100 W 3RD ST
DAYTON OH
45428-9000
US

IV. Provider business mailing address

2525 S PARK LN
CENTERVILLE OH
45458-9386
US

V. Phone/Fax

Practice location:
  • Phone: 937-268-6511
  • Fax:
Mailing address:
  • Phone: 937-268-6511
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code364SA2200X
TaxonomyAdult Health Clinical Nurse Specialist
License Number2008002822
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: