MEDICARE: CAROLYN GREEN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	376K00000X	Nurse's Aide	CNA119128	FL

General Provider Information

NPI Number	:	1548462484
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CAROLYN GREEN

Provider Business Mailing Address
First Line	:	2491 KEEN RD
Second Line	:
City	:	FORT PIERCE
State	:	FL
Zip	:	34946-2006
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2491 KEEN RD
Second Line	:
City	:	FORT PIERCE
State	:	FL
Zip	:	34946-2006
Country	:	US
Telephone Number	:	772-501-2811
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/04/2007
Last Update Date	:	07/08/2007

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Directions to “ CAROLYN GREEN ” Practice Location

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