MEDICARE: KENDRIA GREEN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	164W00000X	Licensed Practical Nurse	PN299707	PA

General Provider Information

NPI Number	:	1003505462
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KENDRIA GREEN

Provider Business Mailing Address
First Line	:	406 VALLEY RD
Second Line	:
City	:	ELKINS PARK
State	:	PA
Zip	:	19027-3209
Country	:	US
Telephone Number	:	267-242-9721
Fax Number	:

Provider Business Practice Location Address
First Line	:	101 WASHINGTON LN # 224
Second Line	:
City	:	JENKINTOWN
State	:	PA
Zip	:	19046-3505
Country	:	US
Telephone Number	:	215-403-6984
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/02/2023
Last Update Date	:	05/02/2023

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Directions to “ KENDRIA GREEN ” Practice Location

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