Provider Demographics
NPI:1467960732
Name:GREEN, JONELLE OLIVIA (OD)
Entity type:Individual
Prefix:
First Name:JONELLE
Middle Name:OLIVIA
Last Name:GREEN
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1816 W 24TH ST
Mailing Address - Street 2:
Mailing Address - City:ERIE
Mailing Address - State:PA
Mailing Address - Zip Code:16502-2022
Mailing Address - Country:US
Mailing Address - Phone:954-559-1957
Mailing Address - Fax:
Practice Address - Street 1:10401 BENNETT RD
Practice Address - Street 2:
Practice Address - City:FREDONIA
Practice Address - State:NY
Practice Address - Zip Code:14063-1402
Practice Address - Country:US
Practice Address - Phone:716-679-3180
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-01-19
Last Update Date:2018-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYTUV008716152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist