Provider Demographics
NPI:1295356616
Name:GREEN, LATIFAH LATRELLE (CMA)
Entity Type:Individual
Prefix:
First Name:LATIFAH
Middle Name:LATRELLE
Last Name:GREEN
Suffix:
Gender:F
Credentials:CMA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8006 JAGUAR DR
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32244-1357
Mailing Address - Country:US
Mailing Address - Phone:904-930-1126
Mailing Address - Fax:
Practice Address - Street 1:8006 JAGUAR DR
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32244-1357
Practice Address - Country:US
Practice Address - Phone:904-930-1126
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-27
Last Update Date:2020-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLG650532875960172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver