Provider Demographics
NPI:1972060440
Name:GREEN, ANGELA CHARISSE (RDN)
Entity Type:Individual
Prefix:
First Name:ANGELA
Middle Name:CHARISSE
Last Name:GREEN
Suffix:
Gender:F
Credentials:RDN
Other - Prefix:
Other - First Name:ANGELA
Other - Middle Name:CHARISSE
Other - Last Name:LAFFERTY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1108 SUMMER BREEZE DR
Mailing Address - Street 2:
Mailing Address - City:BRANDON
Mailing Address - State:FL
Mailing Address - Zip Code:33511-4079
Mailing Address - Country:US
Mailing Address - Phone:214-257-4480
Mailing Address - Fax:
Practice Address - Street 1:1108 SUMMER BREEZE DR
Practice Address - Street 2:
Practice Address - City:BRANDON
Practice Address - State:FL
Practice Address - Zip Code:33511-4079
Practice Address - Country:US
Practice Address - Phone:214-257-4480
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-20
Last Update Date:2019-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL86028496133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered