Provider Demographics
NPI:1821854647
Name:GREEN, KAITLYN (FNP-BC)
Entity Type:Individual
Prefix:
First Name:KAITLYN
Middle Name:
Last Name:GREEN
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:141 RIVERMEADE LN
Mailing Address - Street 2:
Mailing Address - City:BELLEVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62220-3269
Mailing Address - Country:US
Mailing Address - Phone:618-402-7437
Mailing Address - Fax:
Practice Address - Street 1:871 S ARBOR VITAE STE 103
Practice Address - Street 2:
Practice Address - City:EDWARDSVILLE
Practice Address - State:IL
Practice Address - Zip Code:62025-3400
Practice Address - Country:US
Practice Address - Phone:618-685-0799
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-02-28
Last Update Date:2024-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2024005948363LF0000X
IL209029333363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily