Provider Demographics
NPI:1790966158
Name:GREEN, LEE ANN
Entity Type:Individual
Prefix:
First Name:LEE
Middle Name:ANN
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 1:59096 NATHAN GEORGETOWN ST
Mailing Address - Street 2:
Mailing Address - City:PLAQUEMINE
Mailing Address - State:LA
Mailing Address - Zip Code:70764-3073
Mailing Address - Country:US
Mailing Address - Phone:225-385-3155
Mailing Address - Fax:
Practice Address - Street 1:57835 HAASE ST
Practice Address - Street 2:
Practice Address - City:PLAQUEMINE
Practice Address - State:LA
Practice Address - Zip Code:70764-3329
Practice Address - Country:US
Practice Address - Phone:225-687-8137
Practice Address - Fax:225-687-6311
Is Sole Proprietor?:No
Enumeration Date:2007-11-14
Last Update Date:2018-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA140413747A0650X
171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No3747A0650XNursing Service Related ProvidersTechnicianAttendant Care Provider
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1031119Medicaid
LA1008702Medicaid
LA1024503Medicaid