=====================================================
General NPI Number Information
=====================================================
NPI Number | 1023718533
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GREEN WELLNESS NP IN FAMILY HEALTH PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/06/2023
-----------------------------------------------------
Last Update Date | 10/28/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 14 LAFAYETTE SQ STE 2300
-----------------------------------------------------
City | BUFFALO
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 14203-1923
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 267-275-5928
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1420 WISTAR DR
-----------------------------------------------------
City | WYNCOTE
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19095-2313
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 267-275-5928
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | JADE RICKIA GREEN
-----------------------------------------------------
Credential | CRNP
-----------------------------------------------------
Telephone | 267-275-5928
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------