Provider Demographics
NPI:1194371211
Name:GREEN, IRENE BONITA (NURSE PRACTITIONER)
Entity Type:Individual
Prefix:
First Name:IRENE
Middle Name:BONITA
Last Name:GREEN
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9411 LEE HWY APT 813
Mailing Address - Street 2:
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22031-1800
Mailing Address - Country:US
Mailing Address - Phone:571-269-5806
Mailing Address - Fax:
Practice Address - Street 1:3302 GALLOWS RD
Practice Address - Street 2:
Practice Address - City:FALLS CHURCH
Practice Address - State:VA
Practice Address - Zip Code:22042-3353
Practice Address - Country:US
Practice Address - Phone:571-269-5806
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-14
Last Update Date:2019-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024177399363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care