Provider Demographics
NPI:1891050498
Name:GREEN, WANDA LANELL (LPN)
Entity Type:Individual
Prefix:
First Name:WANDA
Middle Name:LANELL
Last Name:GREEN
Suffix:
Gender:F
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:RR 1 BOX 3060
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:OK
Mailing Address - Zip Code:73601-9303
Mailing Address - Country:US
Mailing Address - Phone:580-331-3300
Mailing Address - Fax:580-331-3565
Practice Address - Street 1:RR 1 BOX 3060
Practice Address - Street 2:
Practice Address - City:CLINTON
Practice Address - State:OK
Practice Address - Zip Code:73601-9303
Practice Address - Country:US
Practice Address - Phone:580-331-3300
Practice Address - Fax:580-331-3565
Is Sole Proprietor?:No
Enumeration Date:2012-07-10
Last Update Date:2012-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK34858164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse