Provider Demographics
NPI:1790001576
Name:GREEN, WANDA (RN)
Entity Type:Individual
Prefix:
First Name:WANDA
Middle Name:
Last Name:GREEN
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:475 NEW HWY
Mailing Address - Street 2:
Mailing Address - City:COPIAGUE
Mailing Address - State:NY
Mailing Address - Zip Code:11726-1027
Mailing Address - Country:US
Mailing Address - Phone:631-245-1590
Mailing Address - Fax:
Practice Address - Street 1:475 NEW HWY
Practice Address - Street 2:
Practice Address - City:COPIAGUE
Practice Address - State:NY
Practice Address - Zip Code:11726-1027
Practice Address - Country:US
Practice Address - Phone:631-245-1590
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-04-19
Last Update Date:2010-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY626905163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse