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NPI Code Detail

MEDICARE: DYNASTY DORNAE GREEN RN

MEDICARE: DYNASTY DORNAE GREEN RN
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
1163WP0808XPsychiatric/Mental Health Registered Nurse95379740CA

General Provider Information

NPI Number : 1700711884
Entity Type Code : Individual
Provider Name (Legal Business Name) : DYNASTY DORNAE GREEN RN
Provider Business Mailing Address
First Line : 1512 W 123RD ST
Second Line :
City : LOS ANGELES
State : CA
Zip : 90047-5315
Country : US
Telephone Number : 424-488-3961
Fax Number :
Provider Business Practice Location Address
First Line : 1512 W 123RD ST
Second Line :
City : LOS ANGELES
State : CA
Zip : 90047-5315
Country : US
Telephone Number : 346-573-2757
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 06/17/2026
Last Update Date : 06/17/2026

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