Provider Demographics
NPI:1013268929
Name:GREEN, NICOLE A (NP)
Entity Type:Individual
Prefix:MISS
First Name:NICOLE
Middle Name:A
Last Name:GREEN
Suffix:
Gender:F
Credentials:NP
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Mailing Address - Street 1:3800 ST MARY DR
Mailing Address - Street 2:SUITE 103
Mailing Address - City:VALPARAISO
Mailing Address - State:IN
Mailing Address - Zip Code:46383-7502
Mailing Address - Country:US
Mailing Address - Phone:219-464-2123
Mailing Address - Fax:219-465-0032
Practice Address - Street 1:3800 ST MARY DR
Practice Address - Street 2:SUITE 103
Practice Address - City:VALPARAISO
Practice Address - State:IN
Practice Address - Zip Code:46383-7502
Practice Address - Country:US
Practice Address - Phone:219-464-2123
Practice Address - Fax:219-465-0032
Is Sole Proprietor?:No
Enumeration Date:2012-10-02
Last Update Date:2013-01-31
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
IN28171988A163W00000X
IN71004197A363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse