Provider Demographics
NPI:1861662389
Name:GREEN, DEVIN T SR (LPN)
Entity Type:Individual
Prefix:
First Name:DEVIN
Middle Name:T
Last Name:GREEN
Suffix:SR
Gender:M
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4577 LAKE AVE APT C
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14612-4526
Mailing Address - Country:US
Mailing Address - Phone:585-857-2513
Mailing Address - Fax:
Practice Address - Street 1:4577 LAKE AVE APT C
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14612-4526
Practice Address - Country:US
Practice Address - Phone:585-857-2513
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-03-12
Last Update Date:2008-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY283400-1164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse