Provider Demographics
NPI:1558708073
Name:GREENE, NICOLE ELISE (ATC, LAT)
Entity Type:Individual
Prefix:MS
First Name:NICOLE
Middle Name:ELISE
Last Name:GREENE
Suffix:
Gender:F
Credentials:ATC, LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:75 N FAIRFIELD DR
Mailing Address - Street 2:
Mailing Address - City:SMYRNA
Mailing Address - State:DE
Mailing Address - Zip Code:19977-1516
Mailing Address - Country:US
Mailing Address - Phone:850-339-4369
Mailing Address - Fax:
Practice Address - Street 1:211 EXECUTIVE DR
Practice Address - Street 2:SUITE 11
Practice Address - City:NEWARK
Practice Address - State:DE
Practice Address - Zip Code:19702-3357
Practice Address - Country:US
Practice Address - Phone:302-793-1800
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-05-23
Last Update Date:2014-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAL35212255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer