Healthcare Provider Details

I. General information

NPI: 1336220482
Provider Name (Legal Business Name): GRETA DENISE GREEN CNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/17/2006
Last Update Date: 07/04/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

150 N RENO ST
LOS ANGELES CA
90026-4656
US

IV. Provider business mailing address

150 N RENO ST
LOS ANGELES CA
90026-4656
US

V. Phone/Fax

Practice location:
  • Phone: 213-380-7298
  • Fax:
Mailing address:
  • Phone: 213-380-7298
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number20684
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: