Provider Demographics
NPI:1124896592
Name:GREEN, BEVERLY
Entity type:Individual
Prefix:
First Name:BEVERLY
Middle Name:
Last Name:GREEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:220 VAUGHN ST
Mailing Address - Street 2:
Mailing Address - City:TUSKEGEE
Mailing Address - State:AL
Mailing Address - Zip Code:36083-1923
Mailing Address - Country:US
Mailing Address - Phone:334-421-2790
Mailing Address - Fax:
Practice Address - Street 1:220 VAUGHN ST
Practice Address - Street 2:
Practice Address - City:TUSKEGEE
Practice Address - State:AL
Practice Address - Zip Code:36083-1923
Practice Address - Country:US
Practice Address - Phone:334-421-2790
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-12-15
Last Update Date:2023-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747A0650XNursing Service Related ProvidersTechnicianAttendant Care Provider