Provider Demographics
NPI:1467006601
Name:GREEN, MICHELLE M
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:M
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 1:13709 APOLLO WAY
Mailing Address - Street 2:
Mailing Address - City:ROSEMOUNT
Mailing Address - State:MN
Mailing Address - Zip Code:55068-2171
Mailing Address - Country:US
Mailing Address - Phone:612-743-5590
Mailing Address - Fax:
Practice Address - Street 1:13709 APOLLO WAY
Practice Address - Street 2:
Practice Address - City:ROSEMOUNT
Practice Address - State:MN
Practice Address - Zip Code:55068-2171
Practice Address - Country:US
Practice Address - Phone:612-743-5590
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-25
Last Update Date:2019-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1099384253J00000X, 311ZA0620X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home
No253J00000XAgenciesFoster Care Agency