Healthcare Provider Details

I. General information

NPI: 1902082035
Provider Name (Legal Business Name): PHYLLIS LAVERN GREEN RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/18/2008
Last Update Date: 06/22/2022
Certification Date: 06/22/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10 RACHEL CT
LITTLE ROCK AR
72206-5409
US

IV. Provider business mailing address

16 MARCHWOOD CV
LITTLE ROCK AR
72210-3704
US

V. Phone/Fax

Practice location:
  • Phone: 214-438-7765
  • Fax: 501-847-1100
Mailing address:
  • Phone: 501-541-8311
  • Fax: 501-379-9229

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code3747P1801X
TaxonomyPersonal Care Attendant
License Number
License Number StateAR
# 2
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License NumberR65718
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: