Provider Demographics
NPI:1295502177
Name:GREEN, RANDI NICOLE
Entity type:Individual
Prefix:
First Name:RANDI
Middle Name:NICOLE
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 1:79 ROOSEVELT AVE
Mailing Address - Street 2:
Mailing Address - City:BENWOOD
Mailing Address - State:WV
Mailing Address - Zip Code:26031-1014
Mailing Address - Country:US
Mailing Address - Phone:304-650-3267
Mailing Address - Fax:
Practice Address - Street 1:79 ROOSEVELT AVE
Practice Address - Street 2:
Practice Address - City:BENWOOD
Practice Address - State:WV
Practice Address - Zip Code:26031-1014
Practice Address - Country:US
Practice Address - Phone:304-650-3267
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-12-11
Last Update Date:2023-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV18212062228Medicaid
WV125553494Medicaid
WV1356607394Medicaid