Provider Demographics
NPI:1144557810
Name:GREEN, TERESA (LPN)
Entity type:Individual
Prefix:MS
First Name:TERESA
Middle Name:
Last Name:GREEN
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:151 N MAIN
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:IL
Mailing Address - Zip Code:62523
Mailing Address - Country:US
Mailing Address - Phone:217-362-6262
Mailing Address - Fax:
Practice Address - Street 1:151 N MAIN ST
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:IL
Practice Address - Zip Code:62523-1206
Practice Address - Country:US
Practice Address - Phone:217-362-6262
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-11-17
Last Update Date:2009-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ILT370765549261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center