Healthcare Provider Details

I. General information

NPI: 1457971277
Provider Name (Legal Business Name): MARY GREEN RN, IBCLC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MARY THREESA DONALDSON

II. Dates (important events)

Enumeration Date: 04/22/2020
Last Update Date: 06/04/2020
Certification Date: 06/04/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8821 COLUMBIA 100 PARKWAY
COLUMBIA MD
21045
US

IV. Provider business mailing address

8821 COLUMBIA 100 PARKWAY
COLUMBIA MD
21045
US

V. Phone/Fax

Practice location:
  • Phone: 410-992-0513
  • Fax: 410-740-8315
Mailing address:
  • Phone: 410-992-0513
  • Fax: 410-740-8315

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WL0100X
TaxonomyLactation Consultant (Registered Nurse)
License NumberR082649
License Number StateMD
# 2
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberR082649
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: