Provider Demographics
NPI:1548784622
Name:GREEN, ANGELA ROSE (RD)
Entity Type:Individual
Prefix:
First Name:ANGELA
Middle Name:ROSE
Last Name:GREEN
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:365 MARTIN ST
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19128-4842
Mailing Address - Country:US
Mailing Address - Phone:267-246-1858
Mailing Address - Fax:
Practice Address - Street 1:365 MARTIN ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19128-4842
Practice Address - Country:US
Practice Address - Phone:267-246-1858
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-07-31
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADN006199133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered