Provider Demographics
NPI:1942434295
Name:GREEN, SHANNON (LPN)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:
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 1:821 N MAIN RD APT 45A
Mailing Address - Street 2:
Mailing Address - City:VINELAND
Mailing Address - State:NJ
Mailing Address - Zip Code:08360-8219
Mailing Address - Country:US
Mailing Address - Phone:800-950-6066
Mailing Address - Fax:
Practice Address - Street 1:821 N MAIN RD APT 45A
Practice Address - Street 2:
Practice Address - City:VINELAND
Practice Address - State:NJ
Practice Address - Zip Code:08360-8219
Practice Address - Country:US
Practice Address - Phone:800-950-6066
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-05-14
Last Update Date:2009-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NP06040200164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse