Provider Demographics
NPI:1710646146
Name:GREEN, DEONNA MICHELLE
Entity Type:Individual
Prefix:
First Name:DEONNA
Middle Name:MICHELLE
Last Name:GREEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3305 SPRING MOUNTAIN RD STE 101
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89102-8629
Mailing Address - Country:US
Mailing Address - Phone:725-206-5714
Mailing Address - Fax:
Practice Address - Street 1:1304 SWEENEY AVE
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89104-3348
Practice Address - Country:US
Practice Address - Phone:414-712-8040
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-12-13
Last Update Date:2021-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant