Provider Demographics
NPI:1558833376
Name:GREEN, FALLON LATRICE
Entity Type:Individual
Prefix:
First Name:FALLON
Middle Name:LATRICE
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 1:5967 NW 21ST ST
Mailing Address - Street 2:
Mailing Address - City:LAUDERHILL
Mailing Address - State:FL
Mailing Address - Zip Code:33313-7604
Mailing Address - Country:US
Mailing Address - Phone:305-924-3333
Mailing Address - Fax:
Practice Address - Street 1:5967 NW 21ST ST
Practice Address - Street 2:
Practice Address - City:LAUDERHILL
Practice Address - State:FL
Practice Address - Zip Code:33313-7604
Practice Address - Country:US
Practice Address - Phone:305-924-3333
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-12-18
Last Update Date:2019-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLG650252847490343900000X, 343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)