Provider Demographics
NPI:1184978892
Name:GREEN, MARY CHRISTINE (RN, PCNS-BC)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:CHRISTINE
Last Name:GREEN
Suffix:
Gender:F
Credentials:RN, PCNS-BC
Other - Prefix:
Other - First Name:M
Other - Middle Name:CHRISTINE
Other - Last Name:GREEN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:RN, PCNS-BC
Mailing Address - Street 1:1465 S GRAND BLVD
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63104-1003
Mailing Address - Country:US
Mailing Address - Phone:314-577-5392
Mailing Address - Fax:314-268-6441
Practice Address - Street 1:1465 S GRAND BLVD
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63104-1003
Practice Address - Country:US
Practice Address - Phone:314-577-5392
Practice Address - Fax:314-268-6441
Is Sole Proprietor?:Yes
Enumeration Date:2012-11-01
Last Update Date:2012-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO079924163WP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP0200XNursing Service ProvidersRegistered NursePediatrics