Provider Demographics
NPI:1902082035
Name:GREEN, PHYLLIS LAVERN (RN)
Entity Type:Individual
Prefix:
First Name:PHYLLIS
Middle Name:LAVERN
Last Name:GREEN
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16 MARCHWOOD CV
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72210-3704
Mailing Address - Country:US
Mailing Address - Phone:501-541-8311
Mailing Address - Fax:501-379-9229
Practice Address - Street 1:10 RACHEL CT
Practice Address - Street 2:
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72206-5409
Practice Address - Country:US
Practice Address - Phone:214-438-7765
Practice Address - Fax:501-847-1100
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-18
Last Update Date:2022-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR3747P1801X
ARR65718171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No3747P1801XNursing Service Related ProvidersTechnicianPersonal Care AttendantGroup - Multi-Specialty