Provider Demographics
NPI:1417337775
Name:GREEN, SHERRIS
Entity Type:Individual
Prefix:
First Name:SHERRIS
Middle Name:
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 1:55 COLONIAL HILLS DR
Mailing Address - Street 2:
Mailing Address - City:AKRON
Mailing Address - State:OH
Mailing Address - Zip Code:44310-2360
Mailing Address - Country:US
Mailing Address - Phone:330-351-9752
Mailing Address - Fax:
Practice Address - Street 1:55 COLONIAL HILLS DR
Practice Address - Street 2:
Practice Address - City:AKRON
Practice Address - State:OH
Practice Address - Zip Code:44310-2360
Practice Address - Country:US
Practice Address - Phone:330-351-9752
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-02
Last Update Date:2015-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0103229Medicaid