Provider Demographics
NPI:1891185583
Name:GREEN, LYNNETTE
Entity Type:Individual
Prefix:
First Name:LYNNETTE
Middle Name:
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 1:3101 JEFFERSON DAVIS HWY
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:VA
Mailing Address - Zip Code:22305-3042
Mailing Address - Country:US
Mailing Address - Phone:703-706-3852
Mailing Address - Fax:
Practice Address - Street 1:3101 JEFFERSON DAVIS HWY
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:VA
Practice Address - Zip Code:22305-3042
Practice Address - Country:US
Practice Address - Phone:703-706-3852
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-02-02
Last Update Date:2015-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0230021130183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA0230021130OtherPHARMACY TECHNICIAN LICENSE