Provider Demographics
NPI:1104199652
Name:GREEN, LA'DORIA RICHELLE
Entity Type:Individual
Prefix:
First Name:LA'DORIA
Middle Name:RICHELLE
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 1:7902 CEDAR TURN
Mailing Address - Street 2:
Mailing Address - City:FAIRBURN
Mailing Address - State:GA
Mailing Address - Zip Code:30213-7929
Mailing Address - Country:US
Mailing Address - Phone:770-629-5247
Mailing Address - Fax:
Practice Address - Street 1:7902 CEDAR TURN
Practice Address - Street 2:
Practice Address - City:FAIRBURN
Practice Address - State:GA
Practice Address - Zip Code:30213-7929
Practice Address - Country:US
Practice Address - Phone:770-629-5247
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-02-14
Last Update Date:2012-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1-121056163W00000X
GARN202655163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse