Healthcare Provider Details

I. General information

NPI: 1043089352
Provider Name (Legal Business Name): C GREEN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/28/2023
Last Update Date: 01/04/2024
Certification Date: 01/04/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

323 N CRESCENT DR UNIT 5247
BEVERLY HILLS CA
90210-4883
US

IV. Provider business mailing address

323 N CRESCENT DR UNIT 5247
BEVERLY HILLS CA
90210-4883
US

V. Phone/Fax

Practice location:
  • Phone: 909-333-6573
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number0004252-C-NP
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: