Provider Demographics
NPI:1801465653
Name:GREEN, CALLEY NICHOLE (RN)
Entity type:Individual
Prefix:
First Name:CALLEY
Middle Name:NICHOLE
Last Name:GREEN
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:CALLEY
Other - Middle Name:NICHOLE
Other - Last Name:NEVINS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:800 E MILHAM AVE
Mailing Address - Street 2:
Mailing Address - City:PORTAGE
Mailing Address - State:MI
Mailing Address - Zip Code:49002-1490
Mailing Address - Country:US
Mailing Address - Phone:269-280-9472
Mailing Address - Fax:
Practice Address - Street 1:800 E MILHAM AVE
Practice Address - Street 2:
Practice Address - City:PORTAGE
Practice Address - State:MI
Practice Address - Zip Code:49002-1490
Practice Address - Country:US
Practice Address - Phone:269-280-9472
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-24
Last Update Date:2021-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704292500163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse