Provider Demographics
NPI:1851765812
Name:GREEN, AMANDA CONSTANCE (PHD, RN, MSN, PHCNS)
Entity Type:Individual
Prefix:DR
First Name:AMANDA
Middle Name:CONSTANCE
Last Name:GREEN
Suffix:
Gender:F
Credentials:PHD, RN, MSN, PHCNS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:158 MAGAZINE ST
Mailing Address - Street 2:APT. 6
Mailing Address - City:CAMBRIDGE
Mailing Address - State:MA
Mailing Address - Zip Code:02139-4770
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:415 COLUMBIA RD
Practice Address - Street 2:
Practice Address - City:DORCHESTER
Practice Address - State:MA
Practice Address - Zip Code:02125-2424
Practice Address - Country:US
Practice Address - Phone:617-287-8000
Practice Address - Fax:617-740-8064
Is Sole Proprietor?:Yes
Enumeration Date:2015-11-13
Last Update Date:2015-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN282314163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse