Provider Demographics
NPI:1083993661
Name:GREEN, SUE A (FNP)
Entity Type:Individual
Prefix:
First Name:SUE
Middle Name:A
Last Name:GREEN
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:35 MASON ST
Mailing Address - Street 2:SUITE 214
Mailing Address - City:GENEVA
Mailing Address - State:NY
Mailing Address - Zip Code:14456-1133
Mailing Address - Country:US
Mailing Address - Phone:315-230-5646
Mailing Address - Fax:
Practice Address - Street 1:369 E MAIN ST
Practice Address - Street 2:
Practice Address - City:WATERLOO
Practice Address - State:NY
Practice Address - Zip Code:13165-1654
Practice Address - Country:US
Practice Address - Phone:315-539-4025
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-08-12
Last Update Date:2011-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF336853363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily