Provider Demographics
NPI:1578607958
Name:GREEN, LANETTE (OD)
Entity Type:Individual
Prefix:DR
First Name:LANETTE
Middle Name:
Last Name:GREEN
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1205 20TH AVE S
Mailing Address - Street 2:
Mailing Address - City:SARTELL
Mailing Address - State:MN
Mailing Address - Zip Code:56377-2488
Mailing Address - Country:US
Mailing Address - Phone:337-367-3834
Mailing Address - Fax:
Practice Address - Street 1:206 DIVISION ST
Practice Address - Street 2:
Practice Address - City:WAITE PARK
Practice Address - State:MN
Practice Address - Zip Code:56387-1331
Practice Address - Country:US
Practice Address - Phone:320-253-0365
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-17
Last Update Date:2022-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX6042T152W00000X
LA1393-531T152W00000X
MN3801152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LALA6042OtherEYEMED PROVIDER NUMBER