Provider Demographics
NPI:1366586802
Name:GREEN, VICTORIA LEOLA
Entity type:Individual
Prefix:
First Name:VICTORIA
Middle Name:LEOLA
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 1:655 E BURKITT ST
Mailing Address - Street 2:
Mailing Address - City:SHERIDAN
Mailing Address - State:WY
Mailing Address - Zip Code:82801-4401
Mailing Address - Country:US
Mailing Address - Phone:307-674-6343
Mailing Address - Fax:
Practice Address - Street 1:655 E BURKITT ST
Practice Address - Street 2:
Practice Address - City:SHERIDAN
Practice Address - State:WY
Practice Address - Zip Code:82801-4401
Practice Address - Country:US
Practice Address - Phone:307-674-6343
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY385H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes385H00000XRespite Care FacilityRespite Care