Provider Demographics
NPI:1366961443
Name:GREEN, MICHELE M (RN,BSN,PHN,RNP, MSN)
Entity type:Individual
Prefix:DR
First Name:MICHELE
Middle Name:M
Last Name:GREEN
Suffix:
Gender:F
Credentials:RN,BSN,PHN,RNP, MSN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 452231
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90045-8529
Mailing Address - Country:US
Mailing Address - Phone:323-568-4550
Mailing Address - Fax:
Practice Address - Street 1:11705 ALAMEDA ST
Practice Address - Street 2:
Practice Address - City:LYNWOOD
Practice Address - State:CA
Practice Address - Zip Code:90262-4023
Practice Address - Country:US
Practice Address - Phone:323-568-4550
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-09-11
Last Update Date:2020-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA14185363L00000X, 363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner