Provider Demographics
NPI:1164653549
Name:GREEN, LAURA GERMAINE (OTR)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:GERMAINE
Last Name:GREEN
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8717 ROSALIE AVE
Mailing Address - Street 2:
Mailing Address - City:BRENTWOOD
Mailing Address - State:MO
Mailing Address - Zip Code:63144-2027
Mailing Address - Country:US
Mailing Address - Phone:314-497-9409
Mailing Address - Fax:
Practice Address - Street 1:9645 BIG BEND BLVD
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63122-6521
Practice Address - Country:US
Practice Address - Phone:314-968-5460
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-08-03
Last Update Date:2009-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO000370314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility