Healthcare Provider Details

I. General information

NPI: 1396118634
Provider Name (Legal Business Name): DARICA GREEN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/09/2015
Last Update Date: 11/09/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9730 BAIRD RD APT 1421
SHREVEPORT LA
71118-3822
US

IV. Provider business mailing address

9730 BAIRD RD APT 1421
SHREVEPORT LA
71118-3822
US

V. Phone/Fax

Practice location:
  • Phone: 318-550-7655
  • Fax:
Mailing address:
  • Phone: 318-550-7655
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WM0705X
TaxonomyMedical-Surgical Registered Nurse
License Number140249
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: