Provider Demographics
NPI:1134954845
Name:GREEN, KRISTINA (PEER SPECIALIST)
Entity type:Individual
Prefix:
First Name:KRISTINA
Middle Name:
Last Name:GREEN
Suffix:
Gender:F
Credentials:PEER SPECIALIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1365
Mailing Address - Street 2:
Mailing Address - City:LUSK
Mailing Address - State:WY
Mailing Address - Zip Code:82225-1365
Mailing Address - Country:US
Mailing Address - Phone:307-358-2846
Mailing Address - Fax:
Practice Address - Street 1:905 S MAIN ST
Practice Address - Street 2:
Practice Address - City:LUSK
Practice Address - State:WY
Practice Address - Zip Code:82225-5208
Practice Address - Country:US
Practice Address - Phone:307-334-3666
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-09-03
Last Update Date:2024-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist