Healthcare Provider Details

I. General information

NPI: 1831304658
Provider Name (Legal Business Name): TARA GREEN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/14/2007
Last Update Date: 07/26/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30 E APPLE ST STE 5254A
DAYTON OH
45409-2939
US

IV. Provider business mailing address

30 E APPLE ST STE 5254A
DAYTON OH
45409-2939
US

V. Phone/Fax

Practice location:
  • Phone: 937-208-4200
  • Fax: 937-208-4205
Mailing address:
  • Phone: 937-208-4200
  • Fax: 937-208-4205

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code282NC0060X
TaxonomyCritical Access Hospital
License NumberRN217893
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code364S00000X
TaxonomyClinical Nurse Specialist
License NumberCOA.02166-NS
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: