Provider Demographics
NPI:1982839221
Name:GREEN, LATIA G R
Entity Type:Individual
Prefix:
First Name:LATIA
Middle Name:G R
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 1:2203 OAKLAND FARM DR
Mailing Address - Street 2:
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30044-6394
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2203 OAKLAND FARM DR
Practice Address - Street 2:
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30044-6394
Practice Address - Country:US
Practice Address - Phone:678-429-7176
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-05-15
Last Update Date:2009-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPN077092164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse