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General NPI Number Information
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NPI Number | 1205435641
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Entity Type | Individual
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Provider Name | LILLIE RUTH GREEN
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Gender | Female
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Dates
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Enumeration Date | 10/17/2020
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Last Update Date | 11/30/2022
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Provider Practice Location Address
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Address Line | 278 LASALLE LEFALL DR
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City | QUINCY
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State | FL
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Zip | 32351-5324
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Country | US
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Telephone | 229-726-3984
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Fax |
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Provider Business Mailing Address
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Address Line | 1317 BLOSSOM CIR
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City | TALLAHASSEE
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State | FL
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Zip | 32305-6707
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Country | US
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Telephone | 229-726-3984
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363LF0000X
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Taxonomy Name | Family Nurse Practitioner
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License Number | APRN11007976
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License Number State | FL
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