Provider Demographics
NPI:1467000349
Name:GREEN, KAYLA MAE (RN)
Entity Type:Individual
Prefix:
First Name:KAYLA
Middle Name:MAE
Last Name:GREEN
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 1:129 E PARK AVE APT 6
Mailing Address - Street 2:
Mailing Address - City:WAUKESHA
Mailing Address - State:WI
Mailing Address - Zip Code:53186-4973
Mailing Address - Country:US
Mailing Address - Phone:920-851-1527
Mailing Address - Fax:
Practice Address - Street 1:129 E PARK AVE APT 6
Practice Address - Street 2:
Practice Address - City:WAUKESHA
Practice Address - State:WI
Practice Address - Zip Code:53186-4973
Practice Address - Country:US
Practice Address - Phone:920-851-1527
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-03
Last Update Date:2019-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI249729-30163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
WIKAYMAE2011Medicaid
WI249729-30Medicaid