Provider Demographics
NPI:1093061228
Name:GREEN, MAXINE (RN)
Entity Type:Individual
Prefix:MRS
First Name:MAXINE
Middle Name:
Last Name:GREEN
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:55 BLANK LN
Mailing Address - Street 2:
Mailing Address - City:EMPORIA
Mailing Address - State:VA
Mailing Address - Zip Code:23847-6339
Mailing Address - Country:US
Mailing Address - Phone:804-722-4299
Mailing Address - Fax:804-722-4283
Practice Address - Street 1:55 BLANK LN
Practice Address - Street 2:
Practice Address - City:EMPORIA
Practice Address - State:VA
Practice Address - Zip Code:23847-6339
Practice Address - Country:US
Practice Address - Phone:804-722-4299
Practice Address - Fax:804-722-4283
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-25
Last Update Date:2012-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0001147008163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse