Provider Demographics
NPI:1457059800
Name:GREEN, MIKEIA DEAJANAE
Entity Type:Individual
Prefix:
First Name:MIKEIA
Middle Name:DEAJANAE
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 1:3201 S ST APT 388
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95816-7091
Mailing Address - Country:US
Mailing Address - Phone:602-821-2119
Mailing Address - Fax:
Practice Address - Street 1:4610 X ST
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95817-2200
Practice Address - Country:US
Practice Address - Phone:602-821-2119
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-02-15
Last Update Date:2023-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program