Provider Demographics
NPI:1225873813
Name:GREEN, DONNA (RD/LD)
Entity type:Individual
Prefix:
First Name:DONNA
Middle Name:
Last Name:GREEN
Suffix:
Gender:F
Credentials:RD/LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 438
Mailing Address - Street 2:
Mailing Address - City:SAVANNA
Mailing Address - State:OK
Mailing Address - Zip Code:74565-0438
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3101 ELKS ROAD
Practice Address - Street 2:
Practice Address - City:MCALESTER
Practice Address - State:OK
Practice Address - Zip Code:74501
Practice Address - Country:US
Practice Address - Phone:918-426-2442
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-06-26
Last Update Date:2024-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK781133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered