Healthcare Provider Details

I. General information

NPI: 1245590900
Provider Name (Legal Business Name): STACY A GREEN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/29/2012
Last Update Date: 10/26/2023
Certification Date: 10/26/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6480 NEW HAMPSHIRE AVE
TAKOMA MD
20912
US

IV. Provider business mailing address

6480 NEW HAMPSHIRE AVE
TAKOMA PARK MD
20912-4716
US

V. Phone/Fax

Practice location:
  • Phone: 301-326-4607
  • Fax:
Mailing address:
  • Phone: 202-326-4607
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3747P1801X
TaxonomyPersonal Care Attendant
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code374U00000X
TaxonomyHome Health Aide
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: