Provider Demographics
NPI:1598535767
Name:GREEN, KANDRIA DENISE (PMHNP-BC)
Entity Type:Individual
Prefix:
First Name:KANDRIA
Middle Name:DENISE
Last Name:GREEN
Suffix:
Gender:F
Credentials:PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3794 MS- 468
Mailing Address - Street 2:
Mailing Address - City:PEARL
Mailing Address - State:MS
Mailing Address - Zip Code:39208
Mailing Address - Country:US
Mailing Address - Phone:601-932-2880
Mailing Address - Fax:
Practice Address - Street 1:3794 MS- 468
Practice Address - Street 2:
Practice Address - City:PEARL
Practice Address - State:MS
Practice Address - Zip Code:39208
Practice Address - Country:US
Practice Address - Phone:601-932-2880
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-01-08
Last Update Date:2024-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS906342363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health