Provider Demographics
NPI:1285435834
Name:GREEN, JOHNNIE
Entity type:Individual
Prefix:
First Name:JOHNNIE
Middle Name:
Last Name:GREEN
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8259 INDY CT
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46214-2300
Mailing Address - Country:US
Mailing Address - Phone:317-825-4256
Mailing Address - Fax:317-825-4256
Practice Address - Street 1:8259 INDY CT
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46214-2300
Practice Address - Country:US
Practice Address - Phone:317-825-4256
Practice Address - Fax:317-825-4256
Is Sole Proprietor?:Yes
Enumeration Date:2025-03-20
Last Update Date:2025-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN24-018203-1253Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care