Provider Demographics
NPI:1790340099
Name:GREEN, ELIZABETH
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:
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 1:625 NE 130TH ST
Mailing Address - Street 2:
Mailing Address - City:NORTH MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33161-7524
Mailing Address - Country:US
Mailing Address - Phone:786-768-5855
Mailing Address - Fax:
Practice Address - Street 1:625 NE 130TH ST
Practice Address - Street 2:
Practice Address - City:NORTH MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33161-7524
Practice Address - Country:US
Practice Address - Phone:786-768-5855
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-02
Last Update Date:2019-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL235916251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health