Provider Demographics
NPI:1629826292
Name:GREEN, NIA (GNA)
Entity type:Individual
Prefix:
First Name:NIA
Middle Name:
Last Name:GREEN
Suffix:
Gender:F
Credentials:GNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5507 CHANNING RD
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21229-1007
Mailing Address - Country:US
Mailing Address - Phone:443-740-5172
Mailing Address - Fax:
Practice Address - Street 1:108 GREEN PINE CT APT 1A
Practice Address - Street 2:
Practice Address - City:WINDSOR MILL
Practice Address - State:MD
Practice Address - Zip Code:21244-1394
Practice Address - Country:US
Practice Address - Phone:443-740-5172
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-05-09
Last Update Date:2024-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDAOOO49798376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide