Provider Demographics
NPI:1568115319
Name:GREEN, MICHELLE D
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:D
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:W4073 COUNTY ROAD C
Mailing Address - Street 2:
Mailing Address - City:MONTELLO
Mailing Address - State:WI
Mailing Address - Zip Code:53949-8623
Mailing Address - Country:US
Mailing Address - Phone:608-556-4218
Mailing Address - Fax:
Practice Address - Street 1:W4073 COUNTY ROAD C
Practice Address - Street 2:
Practice Address - City:MONTELLO
Practice Address - State:WI
Practice Address - Zip Code:53949-8623
Practice Address - Country:US
Practice Address - Phone:608-556-4218
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-01
Last Update Date:2022-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes376G00000XNursing Service Related ProvidersNursing Home AdministratorGroup - Multi-Specialty
No251E00000XAgenciesHome Health
No253Z00000XAgenciesIn Home Supportive Care
No311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home
No374U00000XNursing Service Related ProvidersHome Health Aide
No376J00000XNursing Service Related ProvidersHomemaker