Provider Demographics
NPI:1053464065
Name:GREEN, KATHY J (MD, MPH)
Entity type:Individual
Prefix:DR
First Name:KATHY
Middle Name:J
Last Name:GREEN
Suffix:
Gender:F
Credentials:MD, MPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1090 COMMERCE DR
Mailing Address - Street 2:
Mailing Address - City:PRESCOTT
Mailing Address - State:AZ
Mailing Address - Zip Code:86305-3700
Mailing Address - Country:US
Mailing Address - Phone:928-583-1000
Mailing Address - Fax:
Practice Address - Street 1:51 BRIAN MICKELSEN PKWY
Practice Address - Street 2:
Practice Address - City:COTTONWOOD
Practice Address - State:AZ
Practice Address - Zip Code:86326-3610
Practice Address - Country:US
Practice Address - Phone:928-639-8132
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-21
Last Update Date:2025-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ71593207Q00000X
FLME 1181952083P0901X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No2083P0901XAllopathic & Osteopathic PhysiciansPreventive MedicinePublic Health & General Preventive Medicine