Provider Demographics
NPI:1235646274
Name:GREEN, KELLY MICHELLE (REGISTERED NURSE RN)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:MICHELLE
Last Name:GREEN
Suffix:
Gender:F
Credentials:REGISTERED NURSE RN
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:
Other - Last Name:WELLINGTON, GRADEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LPN
Mailing Address - Street 1:2409 HOMER CLAYTON DR
Mailing Address - Street 2:
Mailing Address - City:GUNTERSVILLE
Mailing Address - State:AL
Mailing Address - Zip Code:35976-2207
Mailing Address - Country:US
Mailing Address - Phone:256-582-3203
Mailing Address - Fax:256-582-3216
Practice Address - Street 1:2409 HOMER CLAYTON DR
Practice Address - Street 2:
Practice Address - City:GUNTERSVILLE
Practice Address - State:AL
Practice Address - Zip Code:35976-2207
Practice Address - Country:US
Practice Address - Phone:256-582-3203
Practice Address - Fax:256-582-3216
Is Sole Proprietor?:No
Enumeration Date:2017-12-29
Last Update Date:2017-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1-099590163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse