Provider Demographics
NPI:1629269931
Name:GREEN, THERESA ANN (RDA)
Entity Type:Individual
Prefix:MRS
First Name:THERESA
Middle Name:ANN
Last Name:GREEN
Suffix:
Gender:F
Credentials:RDA
Other - Prefix:MRS
Other - First Name:THERESA
Other - Middle Name:A
Other - Last Name:GREEN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:REGISTERED NURSE
Mailing Address - Street 1:P.O. BOX 2339
Mailing Address - Street 2:
Mailing Address - City:CLARKSVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37042-2339
Mailing Address - Country:US
Mailing Address - Phone:931-553-0919
Mailing Address - Fax:931-553-0971
Practice Address - Street 1:1573 FORT CAMPBELL BLVD
Practice Address - Street 2:
Practice Address - City:CLARKSVILLE
Practice Address - State:TN
Practice Address - Zip Code:37042-3535
Practice Address - Country:US
Practice Address - Phone:931-553-0919
Practice Address - Fax:931-553-0971
Is Sole Proprietor?:No
Enumeration Date:2007-08-05
Last Update Date:2007-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNDA0000010736126800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes126800000XDental ProvidersDental Assistant