Provider Demographics
NPI:1235979527
Name:GREEN, DOMINIQUE CHANTEL
Entity type:Individual
Prefix:
First Name:DOMINIQUE
Middle Name:CHANTEL
Last Name:GREEN
Suffix:
Gender:X
Credentials:
Other - Prefix:
Other - First Name:FRANKIE
Other - Middle Name:
Other - Last Name:GREEN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:296 E 17TH AVE APT 2A
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43201-1707
Mailing Address - Country:US
Mailing Address - Phone:614-209-8641
Mailing Address - Fax:
Practice Address - Street 1:1157 E 25TH AVE
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43211-2113
Practice Address - Country:US
Practice Address - Phone:614-687-9539
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-05-25
Last Update Date:2024-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant