Provider Demographics
NPI:1639043730
Name:GREEN, SHANAE MICHELE
Entity type:Individual
Prefix:
First Name:SHANAE
Middle Name:MICHELE
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 1:1515 NEW GARDEN RD APT 1F
Mailing Address - Street 2:
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27410-1525
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:725 W MAIN ST STE B
Practice Address - Street 2:
Practice Address - City:JAMESTOWN
Practice Address - State:NC
Practice Address - Zip Code:27282-7507
Practice Address - Country:US
Practice Address - Phone:336-252-2711
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-10-01
Last Update Date:2025-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Single Specialty