Provider Demographics
NPI:1528572930
Name:GREEN, TABATHA (LPN)
Entity Type:Individual
Prefix:
First Name:TABATHA
Middle Name:
Last Name:GREEN
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15740 COYLE ST
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48227-2623
Mailing Address - Country:US
Mailing Address - Phone:313-918-9306
Mailing Address - Fax:
Practice Address - Street 1:1221 EAST BRAND BLVD
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48211
Practice Address - Country:US
Practice Address - Phone:734-458-4601
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-11-21
Last Update Date:2017-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4703109730164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse