Individual
NICOLE L GREEN
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Contact information
Practice address
26218 NEWPORT AVE, LOMA LINDA, CA 92354-4120
(909) 677-5111
Mailing address
26218 NEWPORT AVE, LOMA LINDA, CA 92354-4120
(909) 677-5111
Taxonomy
Speciality
Code
Description
License number
State
171W00000X
Contractor
Primary
—
NV
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
171W00000X
—
NV
Enumeration date
07/20/2016
Last updated
08/01/2024
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