Provider Demographics
NPI:1477095123
Name:GREEN, NYEKAZI
Entity Type:Individual
Prefix:
First Name:NYEKAZI
Middle Name:
Last Name:GREEN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:392 MANSFIELD DR
Mailing Address - Street 2:
Mailing Address - City:SLIDELL
Mailing Address - State:LA
Mailing Address - Zip Code:70458-7318
Mailing Address - Country:US
Mailing Address - Phone:504-481-6652
Mailing Address - Fax:985-605-7228
Practice Address - Street 1:392 MANSFIELD DR
Practice Address - Street 2:
Practice Address - City:SLIDELL
Practice Address - State:LA
Practice Address - Zip Code:70458-7318
Practice Address - Country:US
Practice Address - Phone:504-481-6652
Practice Address - Fax:985-605-7228
Is Sole Proprietor?:No
Enumeration Date:2016-11-12
Last Update Date:2017-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor
No172A00000XOther Service ProvidersDriver
No372600000XNursing Service Related ProvidersAdult Companion
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No172V00000XOther Service ProvidersCommunity Health Worker