Provider Demographics
NPI:1972577906
Name:GREEN, MISTY DAWN (DC)
Entity type:Individual
Prefix:DR
First Name:MISTY
Middle Name:DAWN
Last Name:GREEN
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1224 ALABAR LN
Mailing Address - Street 2:
Mailing Address - City:CAPE CORAL
Mailing Address - State:FL
Mailing Address - Zip Code:33909-5102
Mailing Address - Country:US
Mailing Address - Phone:239-772-5777
Mailing Address - Fax:239-214-0675
Practice Address - Street 1:1224 ALABAR LN
Practice Address - Street 2:
Practice Address - City:CAPE CORAL
Practice Address - State:FL
Practice Address - Zip Code:33909
Practice Address - Country:US
Practice Address - Phone:239-772-5777
Practice Address - Fax:239-772-5710
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-15
Last Update Date:2018-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH7917111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLU94691Medicare UPIN
FL53913Medicare ID - Type Unspecified