Provider Demographics
NPI:1538393699
Name:GREEN, NELLA (MD)
Entity type:Individual
Prefix:
First Name:NELLA
Middle Name:
Last Name:GREEN
Suffix:
Gender:F
Credentials:MD
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 1770
Mailing Address - Street 2:
Mailing Address - City:LA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:91944-1770
Mailing Address - Country:US
Mailing Address - Phone:858-312-5459
Mailing Address - Fax:858-345-3743
Practice Address - Street 1:15644 POMERADO RD
Practice Address - Street 2:SUITE 202
Practice Address - City:POWAY
Practice Address - State:CA
Practice Address - Zip Code:92064-2400
Practice Address - Country:US
Practice Address - Phone:858-312-5459
Practice Address - Fax:858-345-3743
Is Sole Proprietor?:Yes
Enumeration Date:2009-05-05
Last Update Date:2017-02-23
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAA113685207RI0200X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine