Provider Demographics
NPI:1306181086
Name:GREEN, ANGELA NICOLE
Entity Type:Individual
Prefix:
First Name:ANGELA
Middle Name:NICOLE
Last Name:GREEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:ANGELA
Other - Middle Name:NICOLE
Other - Last Name:GREEN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:2727 BALDWIN AVE NE
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:OH
Mailing Address - Zip Code:44705-4157
Mailing Address - Country:US
Mailing Address - Phone:330-880-1407
Mailing Address - Fax:
Practice Address - Street 1:2727 BALDWIN AVE NE
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:OH
Practice Address - Zip Code:44705-4157
Practice Address - Country:US
Practice Address - Phone:330-880-1407
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-12-06
Last Update Date:2016-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0158496Medicaid