Provider Demographics
NPI:1699378307
Name:GREEN, LATRAILLE DENISE (PCT)
Entity Type:Individual
Prefix:
First Name:LATRAILLE
Middle Name:DENISE
Last Name:GREEN
Suffix:
Gender:F
Credentials:PCT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4014 E HENRY AVE
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33610-3820
Mailing Address - Country:US
Mailing Address - Phone:813-720-1471
Mailing Address - Fax:888-343-9196
Practice Address - Street 1:4014 E HENRY AVE
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33610-3820
Practice Address - Country:US
Practice Address - Phone:813-720-1471
Practice Address - Fax:888-343-9196
Is Sole Proprietor?:No
Enumeration Date:2020-11-17
Last Update Date:2020-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide