Healthcare Provider Details

I. General information

NPI: 1306790902
Provider Name (Legal Business Name): SHANNEL L. B. GREEN LPN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/23/2026
Last Update Date: 02/23/2026
Certification Date: 02/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2401 E NORTH AVE
BALTIMORE MD
21213-1517
US

IV. Provider business mailing address

9503 OAK TRACE WAY
RANDALLSTOWN MD
21133-2446
US

V. Phone/Fax

Practice location:
  • Phone: 410-675-2113
  • Fax: 410-675-2118
Mailing address:
  • Phone: 410-207-6231
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License NumberLP31343
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: