Healthcare Provider Details

I. General information

NPI: 1275120222
Provider Name (Legal Business Name): DIANA GREEN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/23/2020
Last Update Date: 12/23/2020
Certification Date: 12/23/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7530 W CACTUS RD
PEORIA AZ
85381-5202
US

IV. Provider business mailing address

7586 W KAREN LEE LN
PEORIA AZ
85382-4817
US

V. Phone/Fax

Practice location:
  • Phone: 623-334-4635
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WC1500X
TaxonomyCommunity Health Registered Nurse
License NumberRN201477
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: