Provider Demographics
NPI:1417608357
Name:GREEN, STEPHANIE A (GROUP HOME PROVIDER)
Entity Type:Individual
Prefix:MRS
First Name:STEPHANIE
Middle Name:A
Last Name:GREEN
Suffix:
Gender:F
Credentials:GROUP HOME PROVIDER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4941 GARY DR
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33905-3633
Mailing Address - Country:US
Mailing Address - Phone:239-410-7524
Mailing Address - Fax:239-694-1994
Practice Address - Street 1:4941 GARY DR
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33905-3633
Practice Address - Country:US
Practice Address - Phone:239-410-7524
Practice Address - Fax:239-694-1994
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-12
Last Update Date:2022-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home