Provider Demographics
NPI:1710581137
Name:GREEN, MARY JO
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:JO
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 1:205 HAWKS NEST RD
Mailing Address - Street 2:
Mailing Address - City:MANNINGTON
Mailing Address - State:WV
Mailing Address - Zip Code:26582-6373
Mailing Address - Country:US
Mailing Address - Phone:304-592-0953
Mailing Address - Fax:304-471-2488
Practice Address - Street 1:503 MORGANTOWN AVE
Practice Address - Street 2:
Practice Address - City:FAIRMONT
Practice Address - State:WV
Practice Address - Zip Code:26554-4388
Practice Address - Country:US
Practice Address - Phone:304-363-7375
Practice Address - Fax:304-363-7376
Is Sole Proprietor?:No
Enumeration Date:2020-11-25
Last Update Date:2020-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376J00000XNursing Service Related ProvidersHomemaker