Provider Demographics
NPI:1083604441
Name:GREEN, CONNIE (CFNP)
Entity Type:Individual
Prefix:
First Name:CONNIE
Middle Name:
Last Name:GREEN
Suffix:
Gender:F
Credentials:CFNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 550
Mailing Address - Street 2:
Mailing Address - City:BEAVER
Mailing Address - State:WV
Mailing Address - Zip Code:25813-0550
Mailing Address - Country:US
Mailing Address - Phone:304-255-1300
Mailing Address - Fax:304-255-5391
Practice Address - Street 1:703 RITTER DRIVE
Practice Address - Street 2:
Practice Address - City:BEAVER
Practice Address - State:WV
Practice Address - Zip Code:25813
Practice Address - Country:US
Practice Address - Phone:304-255-1300
Practice Address - Fax:304-253-5391
Is Sole Proprietor?:No
Enumeration Date:2005-10-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV34033163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0166829000Medicaid