Provider Demographics
NPI:1154199180
Name:DOUGLAS-GREEN, MARA MICHELLE (LPN)
Entity type:Individual
Prefix:
First Name:MARA
Middle Name:MICHELLE
Last Name:DOUGLAS-GREEN
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16855 SPRENGER AVE
Mailing Address - Street 2:
Mailing Address - City:EASTPOINTE
Mailing Address - State:MI
Mailing Address - Zip Code:48021-3099
Mailing Address - Country:US
Mailing Address - Phone:313-717-0672
Mailing Address - Fax:
Practice Address - Street 1:16855 SPRENGER AVE
Practice Address - Street 2:
Practice Address - City:EASTPOINTE
Practice Address - State:MI
Practice Address - Zip Code:48021-3099
Practice Address - Country:US
Practice Address - Phone:313-717-0672
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-12-19
Last Update Date:2024-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4703098979164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse