Provider Demographics
NPI:1285817924
Name:GREEN, MARYELLEN BOCZAR (FNP)
Entity Type:Individual
Prefix:
First Name:MARYELLEN
Middle Name:BOCZAR
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 1:5500 CAMPANILE DRIVE
Mailing Address - Street 2:STUDENT HEALTH SERVICES
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92182-4701
Mailing Address - Country:US
Mailing Address - Phone:619-594-5281
Mailing Address - Fax:619-594-3638
Practice Address - Street 1:5500 CAMPANILE DR
Practice Address - Street 2:SDSU STUDENT HEALTH SERVICES
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92182-0001
Practice Address - Country:US
Practice Address - Phone:619-594-5281
Practice Address - Fax:619-594-3638
Is Sole Proprietor?:No
Enumeration Date:2007-12-17
Last Update Date:2007-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA347863390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program