Provider Demographics
NPI:1699409490
Name:GREEN, WILLIE JAMES
Entity Type:Individual
Prefix:
First Name:WILLIE
Middle Name:JAMES
Last Name:GREEN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1825 FELIX AVE
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38114-1714
Mailing Address - Country:US
Mailing Address - Phone:901-832-2011
Mailing Address - Fax:
Practice Address - Street 1:1825 FELIX AVE
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38114-1714
Practice Address - Country:US
Practice Address - Phone:901-832-2011
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-15
Last Update Date:2022-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant