Provider Demographics
NPI:1871245845
Name:GREEN, MARYSSA LATASHA (RN)
Entity Type:Individual
Prefix:MS
First Name:MARYSSA
Middle Name:LATASHA
Last Name:GREEN
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4090 E 93RD ST
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44105-5163
Mailing Address - Country:US
Mailing Address - Phone:216-838-4458
Mailing Address - Fax:
Practice Address - Street 1:4090 E 93RD ST
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44105-5163
Practice Address - Country:US
Practice Address - Phone:216-838-4458
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-01-21
Last Update Date:2023-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRN374156163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse