Provider Demographics
NPI:1033569595
Name:GREEN, ELIZABETH
Entity Type:Individual
Prefix:MRS
First Name:ELIZABETH
Middle Name:
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 1:3203 PINELLAS PL
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33619-6539
Mailing Address - Country:US
Mailing Address - Phone:813-280-9795
Mailing Address - Fax:813-354-4547
Practice Address - Street 1:3203 PINELLAS PL
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33619-6539
Practice Address - Country:US
Practice Address - Phone:813-280-9795
Practice Address - Fax:813-354-4547
Is Sole Proprietor?:No
Enumeration Date:2016-06-15
Last Update Date:2016-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL6906815172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker