Provider Demographics
NPI:1548819634
Name:GREEN, HENRIETTA ANNE (PA-C)
Entity type:Individual
Prefix:
First Name:HENRIETTA
Middle Name:ANNE
Last Name:GREEN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:660 N IDYLLWILD AVE
Mailing Address - Street 2:
Mailing Address - City:RIALTO
Mailing Address - State:CA
Mailing Address - Zip Code:92376-4814
Mailing Address - Country:US
Mailing Address - Phone:909-496-1532
Mailing Address - Fax:
Practice Address - Street 1:17577 ARROW BLVD
Practice Address - Street 2:
Practice Address - City:FONTANA
Practice Address - State:CA
Practice Address - Zip Code:92335-4011
Practice Address - Country:US
Practice Address - Phone:909-823-4454
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-10
Last Update Date:2019-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical