Provider Demographics
NPI:1629334768
Name:GREEN, STEPHANIE E (LPN)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:E
Last Name:GREEN
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:STEPHANIE
Other - Middle Name:E
Other - Last Name:DREHER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LPN
Mailing Address - Street 1:175 FERNWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13205-1438
Mailing Address - Country:US
Mailing Address - Phone:315-254-9278
Mailing Address - Fax:
Practice Address - Street 1:175 FERNWOOD AVE
Practice Address - Street 2:
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13205-1438
Practice Address - Country:US
Practice Address - Phone:315-254-9278
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-03
Last Update Date:2012-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY223203-1164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse