Provider Demographics
NPI:1386107308
Name:GREEN, PRISCILLA JO (RD)
Entity type:Individual
Prefix:MS
First Name:PRISCILLA
Middle Name:JO
Last Name:GREEN
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:HC 63 BOX 30
Mailing Address - Street 2:
Mailing Address - City:PENA BLANCA
Mailing Address - State:NM
Mailing Address - Zip Code:87041-9701
Mailing Address - Country:US
Mailing Address - Phone:505-274-8939
Mailing Address - Fax:
Practice Address - Street 1:351 RED ROCK ROAD
Practice Address - Street 2:
Practice Address - City:LOS CERRILLOS
Practice Address - State:NM
Practice Address - Zip Code:87010
Practice Address - Country:US
Practice Address - Phone:505-274-8939
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-08
Last Update Date:2019-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMLD-0653133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMLD-0653OtherSELF PAY