Provider Demographics
NPI:1497058598
Name:GREEN, ANDREA R
Entity Type:Individual
Prefix:
First Name:ANDREA
Middle Name:R
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 1:201 SINCLAIR LN
Mailing Address - Street 2:
Mailing Address - City:SELAH
Mailing Address - State:WA
Mailing Address - Zip Code:98942-9013
Mailing Address - Country:US
Mailing Address - Phone:509-697-4320
Mailing Address - Fax:
Practice Address - Street 1:201 SINCLAIR LN
Practice Address - Street 2:
Practice Address - City:SELAH
Practice Address - State:WA
Practice Address - Zip Code:98942-9013
Practice Address - Country:US
Practice Address - Phone:509-697-4320
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-12-10
Last Update Date:2011-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WARN60070464163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse