Healthcare Provider Details

I. General information

NPI: 1033072749
Provider Name (Legal Business Name): LATERRA GREEN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/09/2025
Last Update Date: 12/09/2025
Certification Date: 12/09/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2711 WOODLAND AVE
BALTIMORE MD
21215-6525
US

IV. Provider business mailing address

2711 WOODLAND AVE
BALTIMORE MD
21215-6525
US

V. Phone/Fax

Practice location:
  • Phone: 410-301-2718
  • Fax:
Mailing address:
  • Phone: 410-301-2718
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174H00000X
TaxonomyHealth Educator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: