Provider Demographics
NPI:1124369004
Name:GREEN, NICOLE ANN
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:ANN
Last Name:GREEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4341 BOBCAT
Mailing Address - Street 2:
Mailing Address - City:CASPER
Mailing Address - State:WY
Mailing Address - Zip Code:82604-4548
Mailing Address - Country:US
Mailing Address - Phone:307-277-3157
Mailing Address - Fax:
Practice Address - Street 1:4341 BOBCAT
Practice Address - Street 2:
Practice Address - City:CASPER
Practice Address - State:WY
Practice Address - Zip Code:82604-4548
Practice Address - Country:US
Practice Address - Phone:307-277-3157
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-03-02
Last Update Date:2017-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator