Healthcare Provider Details

I. General information

NPI: 1043805286
Provider Name (Legal Business Name): KEYRA GREEN LPN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/09/2021
Last Update Date: 03/09/2021
Certification Date: 03/09/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

199 HAMILTON LN
YEMASSEE SC
29945-4737
US

IV. Provider business mailing address

199 HAMILTON LN
YEMASSEE SC
29945-4737
US

V. Phone/Fax

Practice location:
  • Phone: 843-562-6324
  • Fax:
Mailing address:
  • Phone: 843-562-6324
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License Number49769
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: