Provider Demographics
NPI:1558594549
Name:GREEN, TYESHIA SHANTELL (LPN)
Entity Type:Individual
Prefix:MRS
First Name:TYESHIA
Middle Name:SHANTELL
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 1:4918 N 22ND ST
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53209-5628
Mailing Address - Country:US
Mailing Address - Phone:414-213-0501
Mailing Address - Fax:
Practice Address - Street 1:4918 N 22ND ST
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53209-5628
Practice Address - Country:US
Practice Address - Phone:414-213-0501
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-08-25
Last Update Date:2009-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3050002-031164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse