Provider Demographics
NPI:1043805286
Name:GREEN, KEYRA (LPN)
Entity type:Individual
Prefix:
First Name:KEYRA
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 1:199 HAMILTON LN
Mailing Address - Street 2:
Mailing Address - City:YEMASSEE
Mailing Address - State:SC
Mailing Address - Zip Code:29945-4737
Mailing Address - Country:US
Mailing Address - Phone:843-562-6324
Mailing Address - Fax:
Practice Address - Street 1:199 HAMILTON LN
Practice Address - Street 2:
Practice Address - City:YEMASSEE
Practice Address - State:SC
Practice Address - Zip Code:29945-4737
Practice Address - Country:US
Practice Address - Phone:843-562-6324
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-09
Last Update Date:2021-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC49769164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse