Provider Demographics
NPI:1154872190
Name:GREEN, BIANCA (NP)
Entity type:Individual
Prefix:
First Name:BIANCA
Middle Name:
Last Name:GREEN
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:BIANCA
Other - Middle Name:
Other - Last Name:ZDENEK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2561 ELIZABETH LAKE RD
Mailing Address - Street 2:
Mailing Address - City:WATERFORD
Mailing Address - State:MI
Mailing Address - Zip Code:48328-3313
Mailing Address - Country:US
Mailing Address - Phone:248-682-3300
Mailing Address - Fax:248-682-0026
Practice Address - Street 1:5701 BOW POINTE DR
Practice Address - Street 2:
Practice Address - City:CLARKSTON
Practice Address - State:MI
Practice Address - Zip Code:48346-3198
Practice Address - Country:US
Practice Address - Phone:248-625-2621
Practice Address - Fax:248-625-2621
Is Sole Proprietor?:No
Enumeration Date:2016-10-14
Last Update Date:2017-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704292920363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily