Provider Demographics
NPI:1275119463
Name:GREEN, TERESA
Entity Type:Individual
Prefix:
First Name:TERESA
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 1:30 WOODCREST AVE
Mailing Address - Street 2:
Mailing Address - City:COVINGTON
Mailing Address - State:GA
Mailing Address - Zip Code:30016-7737
Mailing Address - Country:US
Mailing Address - Phone:770-217-1812
Mailing Address - Fax:866-721-4328
Practice Address - Street 1:30 WOODCREST AVE
Practice Address - Street 2:
Practice Address - City:COVINGTON
Practice Address - State:GA
Practice Address - Zip Code:30016-7737
Practice Address - Country:US
Practice Address - Phone:770-217-1812
Practice Address - Fax:866-721-4328
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-19
Last Update Date:2021-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374700000XNursing Service Related ProvidersTechnician