Provider Demographics
NPI:1003582974
Name:GREEN, NICHOLE MARIE (ARNP)
Entity Type:Individual
Prefix:
First Name:NICHOLE
Middle Name:MARIE
Last Name:GREEN
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8503 W CLEARWATER AVE STE B
Mailing Address - Street 2:
Mailing Address - City:KENNEWICK
Mailing Address - State:WA
Mailing Address - Zip Code:99336-3100
Mailing Address - Country:US
Mailing Address - Phone:509-303-3428
Mailing Address - Fax:
Practice Address - Street 1:8503 W CLEARWATER AVE STE B
Practice Address - Street 2:
Practice Address - City:KENNEWICK
Practice Address - State:WA
Practice Address - Zip Code:99336-3100
Practice Address - Country:US
Practice Address - Phone:509-303-3428
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-19
Last Update Date:2021-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAP61208028363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily