Provider Demographics
NPI:1922638733
Name:GREENE, NICOLE
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:GREENE
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 1:22090 JASMINE WAY
Mailing Address - Street 2:
Mailing Address - City:ROGERS
Mailing Address - State:MN
Mailing Address - Zip Code:55374-5803
Mailing Address - Country:US
Mailing Address - Phone:763-442-4127
Mailing Address - Fax:
Practice Address - Street 1:3366 OAKDALE AVE N STE LL
Practice Address - Street 2:
Practice Address - City:ROBBINSDALE
Practice Address - State:MN
Practice Address - Zip Code:55422-2961
Practice Address - Country:US
Practice Address - Phone:763-581-3552
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-01-21
Last Update Date:2020-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN186112-5163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse