Provider Demographics
NPI:1528479797
Name:GREEN, TINA
Entity type:Individual
Prefix:
First Name:TINA
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 1:201 HIGHLAND DR APT 111
Mailing Address - Street 2:
Mailing Address - City:TAYLOR
Mailing Address - State:TX
Mailing Address - Zip Code:76574-1849
Mailing Address - Country:US
Mailing Address - Phone:512-584-1221
Mailing Address - Fax:512-309-4432
Practice Address - Street 1:201 HIGHLAND DR APT 111
Practice Address - Street 2:
Practice Address - City:TAYLOR
Practice Address - State:TX
Practice Address - Zip Code:76574-1849
Practice Address - Country:US
Practice Address - Phone:512-584-1221
Practice Address - Fax:512-309-4432
Is Sole Proprietor?:Yes
Enumeration Date:2014-05-09
Last Update Date:2014-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXS4Y5X8C8374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide