Provider Demographics
NPI:1114390630
Name:GREEN, NICOLE (LMT)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:GREEN
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2360 SWEET HOME RD
Mailing Address - Street 2:SUITE 7 & 8
Mailing Address - City:AMHERST
Mailing Address - State:NY
Mailing Address - Zip Code:14228-2329
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2360 SWEET HOME RD
Practice Address - Street 2:SUITE 7 & 8
Practice Address - City:AMHERST
Practice Address - State:NY
Practice Address - Zip Code:14228-2329
Practice Address - Country:US
Practice Address - Phone:716-564-8800
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-11-05
Last Update Date:2015-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0240411174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist