Provider Demographics
NPI:1104231570
Name:GREEN, LAWRENCE (RN)
Entity type:Individual
Prefix:
First Name:LAWRENCE
Middle Name:
Last Name:GREEN
Suffix:
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6509 NW 105TH AVE
Mailing Address - Street 2:
Mailing Address - City:ALACHUA
Mailing Address - State:FL
Mailing Address - Zip Code:32615-7448
Mailing Address - Country:US
Mailing Address - Phone:909-659-8184
Mailing Address - Fax:
Practice Address - Street 1:6509 NW 105TH AVE
Practice Address - Street 2:
Practice Address - City:ALACHUA
Practice Address - State:FL
Practice Address - Zip Code:32615-7448
Practice Address - Country:US
Practice Address - Phone:909-659-8184
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-24
Last Update Date:2014-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL9344187163WG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WG0100XNursing Service ProvidersRegistered NurseGastroenterology