Healthcare Provider Details

I. General information

NPI: 1295540821
Provider Name (Legal Business Name): RANDALL DEVIN GREEN JR. FNP-C, RN, AE-C, CPN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/11/2025
Last Update Date: 12/16/2025
Certification Date: 12/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2009 WARDS RD
LYNCHBURG VA
24502-5309
US

IV. Provider business mailing address

2009 WARDS RD
LYNCHBURG VA
24502-5309
US

V. Phone/Fax

Practice location:
  • Phone: 302-354-9927
  • Fax:
Mailing address:
  • Phone: 302-354-9927
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number0024194196
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: