Provider Demographics
NPI:1679334296
Name:GREEN, BROOKLYN DYAN
Entity type:Individual
Prefix:
First Name:BROOKLYN
Middle Name:DYAN
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 1:16457 ETT NOECKER RD
Mailing Address - Street 2:
Mailing Address - City:ASHVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:43103-9230
Mailing Address - Country:US
Mailing Address - Phone:740-424-5095
Mailing Address - Fax:
Practice Address - Street 1:16457 ETT NOECKER RD
Practice Address - Street 2:
Practice Address - City:ASHVILLE
Practice Address - State:OH
Practice Address - Zip Code:43103-9230
Practice Address - Country:US
Practice Address - Phone:740-424-5095
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-22
Last Update Date:2024-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376J00000XNursing Service Related ProvidersHomemaker