Provider Demographics
NPI:1396323119
Name:GREEN, MYKENZIE A (NBC-HWC)
Entity type:Individual
Prefix:
First Name:MYKENZIE
Middle Name:A
Last Name:GREEN
Suffix:
Gender:F
Credentials:NBC-HWC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:422 W WHITE ST
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:IL
Mailing Address - Zip Code:61727-2272
Mailing Address - Country:US
Mailing Address - Phone:217-937-5275
Mailing Address - Fax:
Practice Address - Street 1:422 W WHITE ST
Practice Address - Street 2:
Practice Address - City:CLINTON
Practice Address - State:IL
Practice Address - Zip Code:61727-2272
Practice Address - Country:US
Practice Address - Phone:217-937-5275
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-01
Last Update Date:2021-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171400000XOther Service ProvidersHealth & Wellness Coach