Provider Demographics
NPI:1063991438
Name:GREEN, CHERYL ANN
Entity type:Individual
Prefix:
First Name:CHERYL
Middle Name:ANN
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 1:970 E WASHINGTON ST STE 2F
Mailing Address - Street 2:
Mailing Address - City:MEDINA
Mailing Address - State:OH
Mailing Address - Zip Code:44256-2181
Mailing Address - Country:US
Mailing Address - Phone:330-723-7999
Mailing Address - Fax:330-764-9907
Practice Address - Street 1:970 E WASHINGTON ST STE 2F
Practice Address - Street 2:
Practice Address - City:MEDINA
Practice Address - State:OH
Practice Address - Zip Code:44256-2181
Practice Address - Country:US
Practice Address - Phone:330-723-7999
Practice Address - Fax:330-764-9907
Is Sole Proprietor?:No
Enumeration Date:2018-08-07
Last Update Date:2018-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH023179363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner