Provider Demographics
NPI:1679279368
Name:GREEN, LAURA LOUISE (RN)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:LOUISE
Last Name:GREEN
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:LAURA
Other - Middle Name:LOUISE
Other - Last Name:BLOSSER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:43 PALOMAR DR
Mailing Address - Street 2:
Mailing Address - City:CHULA VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:91911-1413
Mailing Address - Country:US
Mailing Address - Phone:619-850-4808
Mailing Address - Fax:
Practice Address - Street 1:43 PALOMAR DR
Practice Address - Street 2:
Practice Address - City:CHULA VISTA
Practice Address - State:CA
Practice Address - Zip Code:91911-1413
Practice Address - Country:US
Practice Address - Phone:619-850-4808
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-02-03
Last Update Date:2023-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95261263163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse