Provider Demographics
NPI:1346623154
Name:GREENE, KELLY L (RN)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:L
Last Name:GREENE
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 621
Mailing Address - Street 2:
Mailing Address - City:WAUSAU
Mailing Address - State:WI
Mailing Address - Zip Code:54402-0621
Mailing Address - Country:US
Mailing Address - Phone:715-432-8133
Mailing Address - Fax:
Practice Address - Street 1:1901 E WAUSAU AVE
Practice Address - Street 2:
Practice Address - City:WAUSAU
Practice Address - State:WI
Practice Address - Zip Code:54403-3158
Practice Address - Country:US
Practice Address - Phone:715-432-8133
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-30
Last Update Date:2015-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI158331163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse