Provider Demographics
NPI:1023214210
Name:GREEN, GALE WILLIAMS
Entity Type:Individual
Prefix:
First Name:GALE
Middle Name:WILLIAMS
Last Name:GREEN
Suffix:
Gender:F
Credentials:
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 11374
Mailing Address - Street 2:
Mailing Address - City:SAINT PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33733-1374
Mailing Address - Country:US
Mailing Address - Phone:727-368-6088
Mailing Address - Fax:727-322-8441
Practice Address - Street 1:4319 QUEENSBORO AVE S
Practice Address - Street 2:
Practice Address - City:SAINT PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33711-2751
Practice Address - Country:US
Practice Address - Phone:727-368-6088
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL6922872 96Medicaid