Provider Demographics
NPI:1851828347
Name:GREEN, BRANDY LATIECHA
Entity Type:Individual
Prefix:MS
First Name:BRANDY
Middle Name:LATIECHA
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 1:4980 S 118TH ST
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68137-2200
Mailing Address - Country:US
Mailing Address - Phone:402-896-3884
Mailing Address - Fax:
Practice Address - Street 1:10011 J ST
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68127-1106
Practice Address - Country:US
Practice Address - Phone:402-896-9988
Practice Address - Fax:402-896-6111
Is Sole Proprietor?:Yes
Enumeration Date:2017-05-16
Last Update Date:2017-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE23140164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse