Provider Demographics
NPI:1376890764
Name:GREEN, SHAREASE A
Entity Type:Individual
Prefix:MS
First Name:SHAREASE
Middle Name:A
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 1:227 IDYLWILD ST NE
Mailing Address - Street 2:
Mailing Address - City:WARREN
Mailing Address - State:OH
Mailing Address - Zip Code:44483-3431
Mailing Address - Country:US
Mailing Address - Phone:330-469-7707
Mailing Address - Fax:
Practice Address - Street 1:227 IDYLWILD ST NE
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:OH
Practice Address - Zip Code:44483-3431
Practice Address - Country:US
Practice Address - Phone:330-469-7707
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-06
Last Update Date:2012-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH400712730108376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide