Provider Demographics
NPI:1942871751
Name:GREEN, COLLETTE KENICE
Entity Type:Individual
Prefix:
First Name:COLLETTE
Middle Name:KENICE
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 1:4407 RENA RD APT 3
Mailing Address - Street 2:
Mailing Address - City:SUITLAND
Mailing Address - State:MD
Mailing Address - Zip Code:20746-3609
Mailing Address - Country:US
Mailing Address - Phone:202-489-9018
Mailing Address - Fax:
Practice Address - Street 1:2515 14TH ST NE APT 4
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20018-1931
Practice Address - Country:US
Practice Address - Phone:202-489-9018
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-03
Last Update Date:2021-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide