Healthcare Provider Details

I. General information

NPI: 1649289091
Provider Name (Legal Business Name): LAKESHUR ROSHA GREEN FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/05/2006
Last Update Date: 03/30/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2955 GULF FWY S
LEAGUE CITY TX
77573-6750
US

IV. Provider business mailing address

9 GREENWAY PLZ SUITE 2950
HOUSTON TX
77046-0905
US

V. Phone/Fax

Practice location:
  • Phone: 281-337-7351
  • Fax: 281-534-4236
Mailing address:
  • Phone: 713-580-9468
  • Fax: 713-358-4801

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number658237
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: