Provider Demographics
NPI:1306824784
Name:GREEN, KATHY E (ARNP)
Entity Type:Individual
Prefix:MS
First Name:KATHY
Middle Name:E
Last Name:GREEN
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16 PHILLIPS ST
Mailing Address - Street 2:
Mailing Address - City:MASSENA
Mailing Address - State:NY
Mailing Address - Zip Code:13662-2016
Mailing Address - Country:US
Mailing Address - Phone:315-764-8076
Mailing Address - Fax:315-764-8079
Practice Address - Street 1:16 PHILLIPS ST
Practice Address - Street 2:
Practice Address - City:MASSENA
Practice Address - State:NY
Practice Address - Zip Code:13662-2016
Practice Address - Country:US
Practice Address - Phone:315-764-8076
Practice Address - Fax:315-764-8079
Is Sole Proprietor?:No
Enumeration Date:2006-01-05
Last Update Date:2023-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF400400363LP0808X
FLARNP9385304363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLY0NM1OtherBCBS
FLHZ336ZMedicare PIN