Provider Demographics
NPI:1770841710
Name:GREEN, TRACEY
Entity Type:Individual
Prefix:
First Name:TRACEY
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 1:41521 W 11 MILE RD
Mailing Address - Street 2:
Mailing Address - City:NOVI
Mailing Address - State:MI
Mailing Address - Zip Code:48375-1803
Mailing Address - Country:US
Mailing Address - Phone:248-299-0030
Mailing Address - Fax:
Practice Address - Street 1:41521 W 11 MILE RD
Practice Address - Street 2:
Practice Address - City:NOVI
Practice Address - State:MI
Practice Address - Zip Code:48375-1803
Practice Address - Country:US
Practice Address - Phone:248-299-0030
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-27
Last Update Date:2016-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4703093647164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse