Healthcare Provider Details

I. General information

NPI: 1700221850
Provider Name (Legal Business Name): NICOLE GREEN M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/02/2013
Last Update Date: 07/11/2020
Certification Date: 07/11/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4800 SAND POINT WAY NE
SEATTLE WA
98105-3901
US

IV. Provider business mailing address

4800 SAND POINT WAY NE
SEATTLE WA
98105-3901
US

V. Phone/Fax

Practice location:
  • Phone: 206-987-2521
  • Fax: 206-987-2721
Mailing address:
  • Phone: 206-987-2521
  • Fax: 206-987-2721

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080P0206X
TaxonomyPediatric Gastroenterology Physician
License NumberMD60643780
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number60643780
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: