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General NPI Number Information
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NPI Number | 1467960732
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Entity Type | Individual
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Provider Name | JONELLE OLIVIA GREEN OD
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Gender | Female
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Dates
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Enumeration Date | 01/19/2018
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Last Update Date | 01/19/2018
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Provider Practice Location Address
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Address Line | 10401 BENNETT RD
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City | FREDONIA
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State | NY
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Zip | 14063-1402
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Country | US
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Telephone | 716-679-3180
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Fax |
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Provider Business Mailing Address
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Address Line | 1816 W 24TH ST
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City | ERIE
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State | PA
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Zip | 16502-2022
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Country | US
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Telephone | 954-559-1957
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 152W00000X
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Taxonomy Name | Optometrist
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License Number | TUV008716
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License Number State | NY
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