Provider Demographics
NPI:1407338403
Name:GREEN, NYSSA (LICAC)
Entity Type:Individual
Prefix:
First Name:NYSSA
Middle Name:
Last Name:GREEN
Suffix:
Gender:F
Credentials:LICAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:250 MAIN ST STE 304
Mailing Address - Street 2:
Mailing Address - City:MONTPELIER
Mailing Address - State:VT
Mailing Address - Zip Code:05602-4257
Mailing Address - Country:US
Mailing Address - Phone:802-552-0615
Mailing Address - Fax:
Practice Address - Street 1:250 MAIN ST STE 304
Practice Address - Street 2:
Practice Address - City:MONTPELIER
Practice Address - State:VT
Practice Address - Zip Code:05602-4257
Practice Address - Country:US
Practice Address - Phone:802-552-0615
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-05
Last Update Date:2023-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT091.0134011171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist