Provider Demographics
NPI:1164091740
Name:GREEN, LAVANTA
Entity Type:Individual
Prefix:
First Name:LAVANTA
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 1:5000 WOODMONT WAY
Mailing Address - Street 2:
Mailing Address - City:ANTIOCH
Mailing Address - State:CA
Mailing Address - Zip Code:94531-8142
Mailing Address - Country:US
Mailing Address - Phone:925-778-9498
Mailing Address - Fax:925-778-9498
Practice Address - Street 1:51 MARINA BLVD
Practice Address - Street 2:
Practice Address - City:PITTSBURG
Practice Address - State:CA
Practice Address - Zip Code:94565-2068
Practice Address - Country:US
Practice Address - Phone:925-252-1111
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-18
Last Update Date:2021-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA15069212OtherKAISER PERMANENTE