Healthcare Provider Details

I. General information

NPI: 1669314340
Provider Name (Legal Business Name): DESTINY C GREEN RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/09/2026
Last Update Date: 04/09/2026
Certification Date: 04/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6100 N 42ND ST # 108
MILWAUKEE WI
53209-3560
US

IV. Provider business mailing address

6100 N 42ND ST # 108
MILWAUKEE WI
53209-3560
US

V. Phone/Fax

Practice location:
  • Phone: 414-795-9761
  • Fax:
Mailing address:
  • Phone: 414-795-9761
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code343900000X
TaxonomyNon-emergency Medical Transport (VAN)
License Number
License Number StateWI
# 3
Primary TaxonomyN
Taxonomy Code385H00000X
TaxonomyRespite Care
License Number
License Number StateWI
# 4
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number1108493-30
License Number StateWI
# 5
Primary TaxonomyN
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: