Provider Demographics
NPI:1154856953
Name:GREEN, ANDREA (STNA)
Entity Type:Individual
Prefix:
First Name:ANDREA
Middle Name:
Last Name:GREEN
Suffix:
Gender:F
Credentials:STNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:115 BATH ST
Mailing Address - Street 2:
Mailing Address - City:ELYRIA
Mailing Address - State:OH
Mailing Address - Zip Code:44035-3501
Mailing Address - Country:US
Mailing Address - Phone:440-494-5192
Mailing Address - Fax:
Practice Address - Street 1:115 BATH ST
Practice Address - Street 2:
Practice Address - City:ELYRIA
Practice Address - State:OH
Practice Address - Zip Code:44035-3501
Practice Address - Country:US
Practice Address - Phone:440-494-5192
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-29
Last Update Date:2017-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH401323941111376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0208731Medicaid