Provider Demographics
NPI:1396524153
Name:GREENE, DEONDRALIQUE LASHAE (NRCMA,CPT)
Entity type:Individual
Prefix:MRS
First Name:DEONDRALIQUE
Middle Name:LASHAE
Last Name:GREENE
Suffix:
Gender:F
Credentials:NRCMA,CPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:3828 CIBOLO DR APT 104
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76133-5576
Mailing Address - Country:US
Mailing Address - Phone:817-401-7344
Mailing Address - Fax:682-708-2617
Practice Address - Street 1:5108 W GORE BLVD STE 1
Practice Address - Street 2:
Practice Address - City:LAWTON
Practice Address - State:OK
Practice Address - Zip Code:73505-6025
Practice Address - Country:US
Practice Address - Phone:866-278-5565
Practice Address - Fax:682-708-2617
Is Sole Proprietor?:Yes
Enumeration Date:2023-09-21
Last Update Date:2024-10-29
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TX246RM2200X
261QC1500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes246RM2200XTechnologists, Technicians & Other Technical Service ProvidersTechnician, PathologyMedical LaboratoryGroup - Multi-Specialty
No261QC1500XAmbulatory Health Care FacilitiesClinic/CenterCommunity Health