Provider Demographics
NPI:1760834683
Name:GREEN, SHANAE
Entity Type:Individual
Prefix:
First Name:SHANAE
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 1:35 VINCENT DR
Mailing Address - Street 2:
Mailing Address - City:MIDDLETOWN
Mailing Address - State:NY
Mailing Address - Zip Code:10940-2932
Mailing Address - Country:US
Mailing Address - Phone:845-661-9917
Mailing Address - Fax:
Practice Address - Street 1:35 VINCENT DR
Practice Address - Street 2:
Practice Address - City:MIDDLETOWN
Practice Address - State:NY
Practice Address - Zip Code:10940-2932
Practice Address - Country:US
Practice Address - Phone:845-661-9917
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-02
Last Update Date:2016-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY688130163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse