Provider Demographics
NPI:1891083887
Name:GREEN, KIMBERLY DAINELLE
Entity Type:Individual
Prefix:MS
First Name:KIMBERLY
Middle Name:DAINELLE
Last Name:GREEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:761 POPLAR ST
Mailing Address - Street 2:SUITE # 2 I
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31201-2082
Mailing Address - Country:US
Mailing Address - Phone:478-461-1955
Mailing Address - Fax:478-745-2054
Practice Address - Street 1:761 POPLAR ST
Practice Address - Street 2:SUITE # 2 I
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31201-2082
Practice Address - Country:US
Practice Address - Phone:478-461-1955
Practice Address - Fax:478-745-2054
Is Sole Proprietor?:Yes
Enumeration Date:2011-07-12
Last Update Date:2011-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA011-R-0210171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor