Provider Demographics
NPI:1760708648
Name:GREEN, LATONYA
Entity Type:Individual
Prefix:MRS
First Name:LATONYA
Middle Name:
Last Name:GREEN
Suffix:
Gender:F
Credentials:
Other - Prefix:MRS
Other - First Name:LATONYA
Other - Middle Name:
Other - Last Name:GREEN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:3902 LINDEN DR
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON
Mailing Address - State:TX
Mailing Address - Zip Code:76017-4637
Mailing Address - Country:US
Mailing Address - Phone:972-660-1920
Mailing Address - Fax:817-563-1272
Practice Address - Street 1:3902 LINDEN DR
Practice Address - Street 2:
Practice Address - City:ARLINGTON
Practice Address - State:TX
Practice Address - Zip Code:76017-4637
Practice Address - Country:US
Practice Address - Phone:972-660-1920
Practice Address - Fax:817-563-1272
Is Sole Proprietor?:Yes
Enumeration Date:2010-04-16
Last Update Date:2010-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX725107171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX725107OtherSTATE