Provider Demographics
NPI:1477079069
Name:GREEN, KATHLEEN R (NP)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:R
Last Name:GREEN
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:202 S PARK ST
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53715-1507
Mailing Address - Country:US
Mailing Address - Phone:608-417-6000
Mailing Address - Fax:
Practice Address - Street 1:6408 COPPS AVE
Practice Address - Street 2:
Practice Address - City:MONONA
Practice Address - State:WI
Practice Address - Zip Code:53716-3702
Practice Address - Country:US
Practice Address - Phone:608-417-3000
Practice Address - Fax:608-417-3300
Is Sole Proprietor?:No
Enumeration Date:2017-08-16
Last Update Date:2019-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI9014363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics