MEDICARE: AGNES MARSEEN GREEN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	164W00000X	Licensed Practical Nurse	298462	NY

General Provider Information

NPI Number	:	1841788841
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	AGNES MARSEEN GREEN

Provider Business Mailing Address
First Line	:	14 POLK PL
Second Line	:
City	:	WHITE PLAINS
State	:	NY
Zip	:	10603-2919
Country	:	US
Telephone Number	:	718-828-2666
Fax Number	:

Provider Business Practice Location Address
First Line	:	14 POLK PL
Second Line	:
City	:	WHITE PLAINS
State	:	NY
Zip	:	10603-2919
Country	:	US
Telephone Number	:	718-828-2666
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/25/2018
Last Update Date	:	04/25/2018

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