=====================================================
General NPI Number Information
=====================================================
NPI Number | 1396583613
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MRS. DOMINIQUE V GREEN
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/19/2024
-----------------------------------------------------
Last Update Date | 07/19/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 122 E MAIN ST # 324
-----------------------------------------------------
City | LAKELAND
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33801-4655
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 863-247-0273
-----------------------------------------------------
Fax | 863-291-3767
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4530 S ORANGE BLOSSOM TRL
-----------------------------------------------------
City | ORLANDO
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32839-1704
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 689-777-2847
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 376J00000X
-----------------------------------------------------
Taxonomy Name | Homemaker
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------