Provider Demographics
NPI:1174256739
Name:GREEN, KATHERINE DENICE
Entity Type:Individual
Prefix:
First Name:KATHERINE
Middle Name:DENICE
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 1:12511 S SOONER ROAD PL
Mailing Address - Street 2:
Mailing Address - City:MOORE
Mailing Address - State:OK
Mailing Address - Zip Code:73165-8105
Mailing Address - Country:US
Mailing Address - Phone:405-794-4647
Mailing Address - Fax:405-794-8541
Practice Address - Street 1:12511 S SOONER ROAD PL
Practice Address - Street 2:
Practice Address - City:MOORE
Practice Address - State:OK
Practice Address - Zip Code:73165-8105
Practice Address - Country:US
Practice Address - Phone:405-794-4647
Practice Address - Fax:405-794-8541
Is Sole Proprietor?:No
Enumeration Date:2022-07-01
Last Update Date:2022-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist