Provider Demographics
NPI:1801395967
Name:GREEN, MARY KIMBERLY (APRN)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:KIMBERLY
Last Name:GREEN
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:880 OLD TRAM RD
Mailing Address - Street 2:
Mailing Address - City:BOWLING GREEN
Mailing Address - State:KY
Mailing Address - Zip Code:42101-9021
Mailing Address - Country:US
Mailing Address - Phone:270-799-2268
Mailing Address - Fax:
Practice Address - Street 1:1035 PORTER PIKE
Practice Address - Street 2:
Practice Address - City:BOWLING GREEN
Practice Address - State:KY
Practice Address - Zip Code:42103-9581
Practice Address - Country:US
Practice Address - Phone:270-843-1199
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-05
Last Update Date:2018-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3011907363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty