Provider Demographics
NPI:1558059527
Name:GREEN, GAYLYNEE (PTA)
Entity Type:Individual
Prefix:
First Name:GAYLYNEE
Middle Name:
Last Name:GREEN
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:700 W CENTRAL AVE STE 206
Mailing Address - Street 2:
Mailing Address - City:EL DORADO
Mailing Address - State:KS
Mailing Address - Zip Code:67042-2186
Mailing Address - Country:US
Mailing Address - Phone:316-452-5113
Mailing Address - Fax:316-452-5171
Practice Address - Street 1:700 W CENTRAL AVE STE 206
Practice Address - Street 2:
Practice Address - City:EL DORADO
Practice Address - State:KS
Practice Address - Zip Code:67042-2186
Practice Address - Country:US
Practice Address - Phone:316-452-5113
Practice Address - Fax:316-452-5171
Is Sole Proprietor?:No
Enumeration Date:2023-04-27
Last Update Date:2023-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS14-01873225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant