Provider Demographics
NPI:1447513858
Name:GREEN-YOUNG, ELLEN LOUISE (RD/LD)
Entity type:Individual
Prefix:MS
First Name:ELLEN
Middle Name:LOUISE
Last Name:GREEN-YOUNG
Suffix:
Gender:F
Credentials:RD/LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 100
Mailing Address - Street 2:
Mailing Address - City:WRIGHT CITY
Mailing Address - State:OK
Mailing Address - Zip Code:74766-0100
Mailing Address - Country:US
Mailing Address - Phone:580-236-3705
Mailing Address - Fax:580-981-7005
Practice Address - Street 1:670 PETUNIA ROAD
Practice Address - Street 2:
Practice Address - City:WRIGHT CITY
Practice Address - State:OK
Practice Address - Zip Code:74766
Practice Address - Country:US
Practice Address - Phone:580-236-3705
Practice Address - Fax:580-981-7005
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-20
Last Update Date:2012-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK879133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered