=====================================================
General NPI Number Information
=====================================================
NPI Number | 1962994756
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SHARROD REYNARD GREENE DNP, CRNA
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/06/2018
-----------------------------------------------------
Last Update Date | 06/03/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 620 JOHN PAUL JONES CIR
-----------------------------------------------------
City | PORTSMOUTH
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23708-2111
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 757-953-5008
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3239 GRANBY ST
-----------------------------------------------------
City | NORFOLK
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23504-1417
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 573-356-8211
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 163W00000X
-----------------------------------------------------
Taxonomy Name | Registered Nurse
-----------------------------------------------------
License Number | 0001267770
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 163W00000X
-----------------------------------------------------
Taxonomy Name | Registered Nurse
-----------------------------------------------------
License Number | RN9351506
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 367500000X
-----------------------------------------------------
Taxonomy Name | Certified Registered Nurse Anesthetist
-----------------------------------------------------
License Number | D177329
-----------------------------------------------------
License Number State | IA
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 367500000X
-----------------------------------------------------
Taxonomy Name | Certified Registered Nurse Anesthetist
-----------------------------------------------------
License Number | 0024176254
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------