Basic Information
| Provider Information | |||||||||
| NPI: | 1063547966 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PRIOLEAU-GREEN | ||||||||
| FirstName: | JIVONNE | ||||||||
| MiddleName: | NIKELL | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | HS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7900A STENTON AVE APT 104 | ||||||||
| Address2: | |||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191183027 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2152426187 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1 WASHINGTON AVE | ||||||||
| Address2: | |||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191474335 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2152714816 | ||||||||
| FaxNumber: | 2152714817 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/22/2007 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1710I1002X | Y | Other Service Providers | Military Health Care Provider | Independent Duty Corpsman |
No ID Information.