Provider Demographics
NPI:1689932543
Name:GREEN, VIRGINIA ANN (LPN)
Entity Type:Individual
Prefix:
First Name:VIRGINIA
Middle Name:ANN
Last Name:GREEN
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:BLDG 14401 15TH & LANE STREET
Mailing Address - Street 2:
Mailing Address - City:FORT GORDON
Mailing Address - State:GA
Mailing Address - Zip Code:30905
Mailing Address - Country:US
Mailing Address - Phone:706-791-1687
Mailing Address - Fax:706-761-1683
Practice Address - Street 1:2997 OLD LODGE RD
Practice Address - Street 2:
Practice Address - City:HEPHZIBAH
Practice Address - State:GA
Practice Address - Zip Code:30815-4994
Practice Address - Country:US
Practice Address - Phone:706-791-1687
Practice Address - Fax:706-791-1683
Is Sole Proprietor?:No
Enumeration Date:2012-04-30
Last Update Date:2012-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPN063962164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse