Provider Demographics
NPI:1144632456
Name:GREEN, CASSANDRA (RN, CSFA)
Entity type:Individual
Prefix:
First Name:CASSANDRA
Middle Name:
Last Name:GREEN
Suffix:
Gender:F
Credentials:RN, CSFA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 309
Mailing Address - Street 2:
Mailing Address - City:MONEE
Mailing Address - State:IL
Mailing Address - Zip Code:60449-0309
Mailing Address - Country:US
Mailing Address - Phone:708-235-0352
Mailing Address - Fax:708-328-3668
Practice Address - Street 1:201 2ND AVE
Practice Address - Street 2:
Practice Address - City:MONTGOMERY
Practice Address - State:IL
Practice Address - Zip Code:60538-1531
Practice Address - Country:US
Practice Address - Phone:630-777-1414
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-05-21
Last Update Date:2015-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL149334246ZC0007X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Assistant