Provider Demographics
NPI:1457971277
Name:GREEN, MARY (RN, IBCLC)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:GREEN
Suffix:
Gender:F
Credentials:RN, IBCLC
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:THREESA
Other - Last Name:DONALDSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:8821 COLUMBIA 100 PARKWAY
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:MD
Mailing Address - Zip Code:21045
Mailing Address - Country:US
Mailing Address - Phone:410-992-0513
Mailing Address - Fax:410-740-8315
Practice Address - Street 1:8821 COLUMBIA 100 PARKWAY
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MD
Practice Address - Zip Code:21045
Practice Address - Country:US
Practice Address - Phone:410-992-0513
Practice Address - Fax:410-740-8315
Is Sole Proprietor?:No
Enumeration Date:2020-04-22
Last Update Date:2020-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR082649163WL0100X, 163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
No163WL0100XNursing Service ProvidersRegistered NurseLactation Consultant