Provider Demographics
NPI:1558031583
Name:GREEN, SANDRA (LPN)
Entity Type:Individual
Prefix:
First Name:SANDRA
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 1:4490 RAMBLEWOOD DR
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80920-6634
Mailing Address - Country:US
Mailing Address - Phone:719-217-4544
Mailing Address - Fax:
Practice Address - Street 1:1650 COCHRANE CIR BLDG 2361
Practice Address - Street 2:
Practice Address - City:FORT CARSON
Practice Address - State:CO
Practice Address - Zip Code:80913-4613
Practice Address - Country:US
Practice Address - Phone:719-524-3715
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-20
Last Update Date:2021-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COPN.0331410164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse