Provider Demographics
NPI:1386701761
Name:GREEN, PAULA S (LPN)
Entity type:Individual
Prefix:
First Name:PAULA
Middle Name:S
Last Name:GREEN
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17 COBB AVE
Mailing Address - Street 2:PO BOX 162
Mailing Address - City:DELEVAN
Mailing Address - State:NY
Mailing Address - Zip Code:14042-0162
Mailing Address - Country:US
Mailing Address - Phone:716-560-7764
Mailing Address - Fax:
Practice Address - Street 1:17 COBB AVE
Practice Address - Street 2:
Practice Address - City:DELEVAN
Practice Address - State:NY
Practice Address - Zip Code:14042-0162
Practice Address - Country:US
Practice Address - Phone:716-560-7764
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY224473-1164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02572012Medicaid