Provider Information for 1649879461
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JOYCELYN GREEN
Sex: Female
NPI: 1649879461
Last Updated: 2022-01-07
Certification Date: 2022-01-07
Certification Date: 2022-01-07
Details
| Name | Value | ||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| NPI | 1649879461 | ||||||||||||
| Enumeration Date | 2020-10-22 | ||||||||||||
| NPI Type | NPI-1 Individual | ||||||||||||
| Sole Proprietor | NO | ||||||||||||
| Status | Active | ||||||||||||
| Mailing Address | 1110 CLAY ST VICKSBURG, MS 39183-2912 United States Phone: 601-738-5820 | Fax:601-738-5083 | ||||||||||||
| Primary Practice Address | 1110 CLAY ST VICKSBURG, MS 39183-2912 United States Phone: 601-738-5820 | Fax:601-738-5083 | ||||||||||||
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