MEDICARE: MADENA LESA GREEN LPN

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	164W00000X	Licensed Practical Nurse	PN.128018-MEDS-IV	OH

General Provider Information

NPI Number	:	1851844310
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MADENA LESA GREEN LPN

Provider Business Mailing Address
First Line	:	9978 MAGNOLIA DR
Second Line	:
City	:	OLMSTED FALLS
State	:	OH
Zip	:	44138-2702
Country	:	US
Telephone Number	:	216-310-4976
Fax Number	:

Provider Business Practice Location Address
First Line	:	9978 MAGNOLIA DR
Second Line	:
City	:	OLMSTED FALLS
State	:	OH
Zip	:	44138-2702
Country	:	US
Telephone Number	:	216-310-4976
Fax Number	:

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

Provider Enumeration Date	:	08/01/2016
Last Update Date	:	08/01/2016

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