Healthcare Provider Details

I. General information

NPI: 1639382807
Provider Name (Legal Business Name): LAGRETTA GREEN NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/07/2007
Last Update Date: 06/24/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 E 115TH ST
CHICAGO IL
60628-5015
US

IV. Provider business mailing address

200 E 115TH ST
CHICAGO IL
60628-5015
US

V. Phone/Fax

Practice location:
  • Phone: 312-747-2823
  • Fax: 312-747-2851
Mailing address:
  • Phone: 312-747-9505
  • Fax: 312-747-2851

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LC1500X
TaxonomyCommunity Health Nurse Practitioner
License Number209-000642
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: