Basic Information
| Provider Information | |||||||||
| NPI: | 1003450388 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GREEN | ||||||||
| FirstName: | MARY | ||||||||
| MiddleName: | ELIZABETH | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | LPN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 284 EXECUTIVE PARK DR STE 100 | ||||||||
| Address2: | |||||||||
| City: | CONCORD | ||||||||
| State: | NC | ||||||||
| PostalCode: | 280251833 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7049391100 | ||||||||
| FaxNumber: | 7049391173 | ||||||||
| Practice Location | |||||||||
| Address1: | 650 HIGHLAND AVE # 100 | ||||||||
| Address2: | |||||||||
| City: | WINSTON SALEM | ||||||||
| State: | NC | ||||||||
| PostalCode: | 271014304 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3366078523 | ||||||||
| FaxNumber: | 3367730914 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/30/2019 | ||||||||
| LastUpdateDate: | 10/30/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 164W00000X | 76633 | NC | Y | Nursing Service Providers | Licensed Practical Nurse |
No ID Information.