=====================================================
General NPI Number Information
=====================================================
NPI Number | 1952870214
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | STEPHANIE RAE GREEN I RN
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/16/2018
-----------------------------------------------------
Last Update Date | 11/16/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1228 CONSIDINE AVE
-----------------------------------------------------
City | CINCINNATI
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 45204-1604
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 513-363-6021
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1935 CRUEY LN
-----------------------------------------------------
City | BATAVIA
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 45103-8494
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 513-545-8860
-----------------------------------------------------
Fax | 513-363-6020
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 163W00000X
-----------------------------------------------------
Taxonomy Name | Registered Nurse
-----------------------------------------------------
License Number | 304839
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------