Provider Demographics
NPI:1992340780
Name:GREEN, NIKOLE L
Entity type:Individual
Prefix:
First Name:NIKOLE
Middle Name:L
Last Name:GREEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:421 S BUTLER BLVD APT 1
Mailing Address - Street 2:
Mailing Address - City:LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48915-2527
Mailing Address - Country:US
Mailing Address - Phone:517-371-1111
Mailing Address - Fax:517-371-1121
Practice Address - Street 1:2025 S WASHINGTON AVE STE 210
Practice Address - Street 2:
Practice Address - City:LANSING
Practice Address - State:MI
Practice Address - Zip Code:48910-0817
Practice Address - Country:US
Practice Address - Phone:517-371-1111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-11-15
Last Update Date:2019-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4703096060164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse