Provider Demographics
NPI:1790798395
Name:GREEN, TINA MARIE
Entity Type:Individual
Prefix:MRS
First Name:TINA
Middle Name:MARIE
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:PO BOX 326
Mailing Address - Street 2:
Mailing Address - City:LANSING
Mailing Address - State:OH
Mailing Address - Zip Code:43934-0326
Mailing Address - Country:US
Mailing Address - Phone:740-359-0863
Mailing Address - Fax:
Practice Address - Street 1:68429 TERRACE ST
Practice Address - Street 2:
Practice Address - City:LANSING
Practice Address - State:OH
Practice Address - Zip Code:43934-0326
Practice Address - Country:US
Practice Address - Phone:740-359-0863
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2487045Medicaid