Provider Demographics
NPI:1285095182
Name:GREEN, DEANNA LORRAINE
Entity type:Individual
Prefix:MS
First Name:DEANNA
Middle Name:LORRAINE
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 1:23 REED BLVD STE 120
Mailing Address - Street 2:
Mailing Address - City:MILL VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:94941-2370
Mailing Address - Country:US
Mailing Address - Phone:415-795-7000
Mailing Address - Fax:
Practice Address - Street 1:23 REED BLVD STE 120
Practice Address - Street 2:
Practice Address - City:MILL VALLEY
Practice Address - State:CA
Practice Address - Zip Code:94941-2370
Practice Address - Country:US
Practice Address - Phone:415-795-7000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-03-19
Last Update Date:2019-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA165296207R00000X
ORPG195048207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine