Provider Demographics
NPI:1477112258
Name:GREEN, SHANIQUA
Entity Type:Individual
Prefix:
First Name:SHANIQUA
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 1:1025 W CHURCH ST APT 612
Mailing Address - Street 2:
Mailing Address - City:LIVINGSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77351-3065
Mailing Address - Country:US
Mailing Address - Phone:936-933-7973
Mailing Address - Fax:
Practice Address - Street 1:1025 W CHURCH ST APT 612
Practice Address - Street 2:
Practice Address - City:LIVINGSTON
Practice Address - State:TX
Practice Address - Zip Code:77351-3065
Practice Address - Country:US
Practice Address - Phone:936-933-7973
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-06
Last Update Date:2019-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX347110164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse