Healthcare Provider Details

I. General information

NPI: 1467738260
Provider Name (Legal Business Name): DEBORAH LYNN GREEN RDLD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/25/2011
Last Update Date: 10/25/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2980 SE 3RD CT
OCALA FL
34471-0421
US

IV. Provider business mailing address

2980 SE 3RD CT
OCALA FL
34471-0421
US

V. Phone/Fax

Practice location:
  • Phone: 352-622-4231
  • Fax: 352-622-0513
Mailing address:
  • Phone: 352-622-4231
  • Fax: 352-622-0513

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberND1679
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: