Provider Demographics
NPI:1942655741
Name:GREEN, DENEEN
Entity Type:Individual
Prefix:
First Name:DENEEN
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 1:15814 JEFFERSON DAVIS HWY
Mailing Address - Street 2:
Mailing Address - City:SOUTH CHESTERFIELD
Mailing Address - State:VA
Mailing Address - Zip Code:23834-5202
Mailing Address - Country:US
Mailing Address - Phone:804-451-1455
Mailing Address - Fax:804-524-2435
Practice Address - Street 1:15814 JEFFERSON DAVIS HWY
Practice Address - Street 2:
Practice Address - City:SOUTH CHESTERFIELD
Practice Address - State:VA
Practice Address - Zip Code:23834-5202
Practice Address - Country:US
Practice Address - Phone:804-451-1455
Practice Address - Fax:804-524-2435
Is Sole Proprietor?:No
Enumeration Date:2016-04-28
Last Update Date:2016-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA361172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver