Provider Demographics
NPI:1376966390
Name:GREEN, NYISHA O (CNA, CMA)
Entity Type:Individual
Prefix:
First Name:NYISHA
Middle Name:O
Last Name:GREEN
Suffix:
Gender:F
Credentials:CNA, CMA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1177 REILEY CT
Mailing Address - Street 2:
Mailing Address - City:RACINE
Mailing Address - State:WI
Mailing Address - Zip Code:53403-1759
Mailing Address - Country:US
Mailing Address - Phone:262-308-2961
Mailing Address - Fax:262-260-8433
Practice Address - Street 1:1177 REILEY CT
Practice Address - Street 2:
Practice Address - City:RACINE
Practice Address - State:WI
Practice Address - Zip Code:53403-1759
Practice Address - Country:US
Practice Address - Phone:260-308-2961
Practice Address - Fax:262-260-8433
Is Sole Proprietor?:Yes
Enumeration Date:2014-01-27
Last Update Date:2014-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAH5K8N2B6374700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374700000XNursing Service Related ProvidersTechnician