Provider Demographics
NPI:1316935620
Name:GREEN, JOLEEN MARIE (RD LDN CDE)
Entity type:Individual
Prefix:MS
First Name:JOLEEN
Middle Name:MARIE
Last Name:GREEN
Suffix:
Gender:F
Credentials:RD LDN CDE
Other - Prefix:
Other - First Name:JOLEEN
Other - Middle Name:MARIE
Other - Last Name:SHUEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RD LDN CDE
Mailing Address - Street 1:125 E 34TH ST
Mailing Address - Street 2:
Mailing Address - City:ERIE
Mailing Address - State:PA
Mailing Address - Zip Code:16504-1509
Mailing Address - Country:US
Mailing Address - Phone:814-335-4147
Mailing Address - Fax:
Practice Address - Street 1:125 E 34TH ST
Practice Address - Street 2:
Practice Address - City:ERIE
Practice Address - State:PA
Practice Address - Zip Code:16504-1509
Practice Address - Country:US
Practice Address - Phone:814-335-4147
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-11
Last Update Date:2011-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADN003333133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA094178QNCMedicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER