Provider Demographics
NPI:1568160679
Name:GREEN, KEAUNA TYSHEMA
Entity Type:Individual
Prefix:
First Name:KEAUNA
Middle Name:TYSHEMA
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 1:7029 ALDEN RD
Mailing Address - Street 2:
Mailing Address - City:PIKESVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:21208-6038
Mailing Address - Country:US
Mailing Address - Phone:443-622-7832
Mailing Address - Fax:
Practice Address - Street 1:3610 GREENMOUNT AVE
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21218-2510
Practice Address - Country:US
Practice Address - Phone:443-226-1566
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-02-17
Last Update Date:2023-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR237797163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse