Healthcare Provider Details

I. General information

NPI: 1346545662
Provider Name (Legal Business Name): MRS. LAVORNE BLYDEN-GREEN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/18/2011
Last Update Date: 05/29/2026
Certification Date: 05/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7733 TOWN CT
JONESBORO GA
30236-2395
US

IV. Provider business mailing address

PO BOX 2312
JONESBORO GA
30237-2312
US

V. Phone/Fax

Practice location:
  • Phone: 404-781-8166
  • Fax:
Mailing address:
  • Phone: 404-781-8166
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code332BC3200X
TaxonomyCustomized Equipment (DME)
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code332BX2000X
TaxonomyOxygen Equipment & Supplies (DME)
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code335E00000X
TaxonomyProsthetic/Orthotic Supplier
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License Number346089-01
License Number StateNY
# 6
Primary TaxonomyN
Taxonomy Code335V00000X
TaxonomyPortable X-ray and/or Other Portable Diagnostic Imaging Supplier
License Number
License Number State
# 7
Primary TaxonomyN
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License NumberPN5264319
License Number StateFL
# 8
Primary TaxonomyN
Taxonomy Code332BD1200X
TaxonomyDialysis Equipment & Supplies (DME)
License Number
License Number State
# 9
Primary TaxonomyN
Taxonomy Code332U00000X
TaxonomyHome Delivered Meals
License Number
License Number State
# 10
Primary TaxonomyN
Taxonomy Code332BN1400X
TaxonomyNursing Facility Supplies (DME)
License Number
License Number State
# 11
Primary TaxonomyN
Taxonomy Code332900000X
TaxonomyNon-Pharmacy Dispensing Site
License Number
License Number State
# 12
Primary TaxonomyN
Taxonomy Code332BP3500X
TaxonomyParenteral & Enteral Nutrition Supplies (DME)
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: