Healthcare Provider Details

I. General information

NPI: 1700936713
Provider Name (Legal Business Name): BRANDI MARIE GREEN R.N.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/11/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

801 S MILWAUKEE AVE
LIBERTYVILLE IL
60048-3204
US

IV. Provider business mailing address

1880 INTREPID ST APT B
GREAT LAKES IL
60088-1256
US

V. Phone/Fax

Practice location:
  • Phone: 847-990-5300
  • Fax:
Mailing address:
  • Phone: 847-473-9165
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WE0003X
TaxonomyEmergency Registered Nurse
License NumberRN00151370
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code163WE0003X
TaxonomyEmergency Registered Nurse
License Number
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: