Provider Demographics
NPI:1952156788
Name:GREEN, MELISSA
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:
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 1:7617 EUNICE DR
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28306-8620
Mailing Address - Country:US
Mailing Address - Phone:609-686-5525
Mailing Address - Fax:
Practice Address - Street 1:7617 EUNICE DR
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28306-8620
Practice Address - Country:US
Practice Address - Phone:609-686-5525
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-04-23
Last Update Date:2024-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC171400000X
NCC655541744P3200X, 335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
No171400000XOther Service ProvidersHealth & Wellness CoachGroup - Multi-Specialty
No1744P3200XOther Service ProvidersSpecialistProsthetics Case ManagementGroup - Multi-Specialty