Provider Demographics
NPI:1871317354
Name:GREEN, NYASIA
Entity type:Individual
Prefix:
First Name:NYASIA
Middle Name:
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 1:2211 DR ANDREW J BROWN AVE
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46205-4527
Mailing Address - Country:US
Mailing Address - Phone:317-519-5403
Mailing Address - Fax:
Practice Address - Street 1:3890 N KEYSTONE AVE
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46205-2909
Practice Address - Country:US
Practice Address - Phone:317-519-5403
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-11-12
Last Update Date:2024-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN24-018086-1253Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care