Provider Demographics
NPI:1972336410
Name:GREEN, FELICA LANETA
Entity type:Individual
Prefix:
First Name:FELICA
Middle Name:LANETA
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 1:1102 W PRESIDENT AVE
Mailing Address - Street 2:
Mailing Address - City:GREENWOOD
Mailing Address - State:MS
Mailing Address - Zip Code:38930-2831
Mailing Address - Country:US
Mailing Address - Phone:662-466-1691
Mailing Address - Fax:
Practice Address - Street 1:1102 W PRESIDENT AVE
Practice Address - Street 2:
Practice Address - City:GREENWOOD
Practice Address - State:MS
Practice Address - Zip Code:38930-2831
Practice Address - Country:US
Practice Address - Phone:662-466-1691
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-08-21
Last Update Date:2024-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS57890376K00000X
347C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes347C00000XTransportation ServicesPrivate Vehicle
No376K00000XNursing Service Related ProvidersNurse's AideGroup - Single Specialty