Provider Demographics
NPI:1972675395
Name:GREENE, MARY (APRN)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:GREENE
Suffix:
Gender:F
Credentials:APRN
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Mailing Address - Street 1:55 WEST MAIN STREET
Mailing Address - Street 2:WESTERN CONNECTICUT MENTAL HEALTH NETWORK SUITE 410
Mailing Address - City:WATERBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06702
Mailing Address - Country:US
Mailing Address - Phone:203-805-6408
Mailing Address - Fax:203-805-6432
Practice Address - Street 1:55 WEST MAIN STREET
Practice Address - Street 2:WESTERN CONNECTICUT MENTAL HEALTH NETWORK SUITE 410
Practice Address - City:WATERBURY
Practice Address - State:CT
Practice Address - Zip Code:06702
Practice Address - Country:US
Practice Address - Phone:203-805-6408
Practice Address - Fax:203-805-6432
Is Sole Proprietor?:No
Enumeration Date:2006-11-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CT002425364S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364S00000XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
P22244Medicare UPIN