Provider Demographics
NPI:1083002430
Name:GREEN, NICOLE RENEE (DVM)
Entity Type:Individual
Prefix:DR
First Name:NICOLE
Middle Name:RENEE
Last Name:GREEN
Suffix:
Gender:F
Credentials:DVM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14370 PARALLEL RD
Mailing Address - Street 2:
Mailing Address - City:BASEHOR
Mailing Address - State:KS
Mailing Address - Zip Code:66007-3004
Mailing Address - Country:US
Mailing Address - Phone:913-724-1919
Mailing Address - Fax:913-724-2013
Practice Address - Street 1:14370 PARALLEL RD
Practice Address - Street 2:
Practice Address - City:BASEHOR
Practice Address - State:KS
Practice Address - Zip Code:66007-3004
Practice Address - Country:US
Practice Address - Phone:913-724-1919
Practice Address - Fax:913-724-2013
Is Sole Proprietor?:Yes
Enumeration Date:2015-01-07
Last Update Date:2015-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS6612174M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174M00000XOther Service ProvidersVeterinarian