Provider Demographics
NPI:1902187909
Name:GREEN, KIMBERLY (NP-C)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:
Last Name:GREEN
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11838 193RD ST
Mailing Address - Street 2:
Mailing Address - City:SAINT ALBANS
Mailing Address - State:NY
Mailing Address - Zip Code:11412-3339
Mailing Address - Country:US
Mailing Address - Phone:646-492-4268
Mailing Address - Fax:
Practice Address - Street 1:11838 193RD ST
Practice Address - Street 2:
Practice Address - City:SAINT ALBANS
Practice Address - State:NY
Practice Address - Zip Code:11412-3339
Practice Address - Country:US
Practice Address - Phone:646-492-4268
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-02
Last Update Date:2019-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF342570-1363LF0000X
NY6421131163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily