Provider Demographics
NPI:1609364363
Name:GREEN, MICHELLE
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
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 1:1033 PARK MEADOWS RD
Mailing Address - Street 2:
Mailing Address - City:CHULA VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:91915-1414
Mailing Address - Country:US
Mailing Address - Phone:917-860-0192
Mailing Address - Fax:
Practice Address - Street 1:10201 MISSION GORGE RD STE O
Practice Address - Street 2:
Practice Address - City:SANTEE
Practice Address - State:CA
Practice Address - Zip Code:92071-3040
Practice Address - Country:US
Practice Address - Phone:619-383-6862
Practice Address - Fax:619-312-2661
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-27
Last Update Date:2018-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist