Provider Demographics
NPI:1063547966
Name:PRIOLEAU-GREEN, JIVONNE NIKELL (HS)
Entity type:Individual
Prefix:MS
First Name:JIVONNE
Middle Name:NIKELL
Last Name:PRIOLEAU-GREEN
Suffix:
Gender:F
Credentials:HS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7900A STENTON AVE APT 104
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19118-3027
Mailing Address - Country:US
Mailing Address - Phone:215-242-6187
Mailing Address - Fax:
Practice Address - Street 1:1 WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19147-4335
Practice Address - Country:US
Practice Address - Phone:215-271-4816
Practice Address - Fax:215-271-4817
Is Sole Proprietor?:No
Enumeration Date:2007-02-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman