Provider Demographics
NPI:1316396286
Name:GREEN, KEYANDRA
Entity Type:Individual
Prefix:
First Name:KEYANDRA
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 1:3250 SOUTHFIELD DR
Mailing Address - Street 2:
Mailing Address - City:SAGINAW
Mailing Address - State:MI
Mailing Address - Zip Code:48601-5642
Mailing Address - Country:US
Mailing Address - Phone:989-213-7141
Mailing Address - Fax:
Practice Address - Street 1:3250 SOUTHFIELD DR
Practice Address - Street 2:
Practice Address - City:SAGINAW
Practice Address - State:MI
Practice Address - Zip Code:48601-5642
Practice Address - Country:US
Practice Address - Phone:989-213-7141
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-06-10
Last Update Date:2016-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other