Provider Demographics
NPI:1033456983
Name:GREEN, KENYOTTA E (LPN)
Entity Type:Individual
Prefix:
First Name:KENYOTTA
Middle Name:E
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 1:5781 STONE GATE HTS APT 6
Mailing Address - Street 2:
Mailing Address - City:JAMESVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:13078-4512
Mailing Address - Country:US
Mailing Address - Phone:315-450-3358
Mailing Address - Fax:
Practice Address - Street 1:5781 STONE GATE HTS APT 6
Practice Address - Street 2:
Practice Address - City:JAMESVILLE
Practice Address - State:NY
Practice Address - Zip Code:13078-4512
Practice Address - Country:US
Practice Address - Phone:315-450-3358
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-01-12
Last Update Date:2013-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY10 283969164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse