Provider Demographics
NPI:1396461604
Name:GREEN, KAWANZA S
Entity type:Individual
Prefix:
First Name:KAWANZA
Middle Name:S
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 1:3022 GUAVA ST
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33916-1910
Mailing Address - Country:US
Mailing Address - Phone:239-295-1803
Mailing Address - Fax:239-939-7731
Practice Address - Street 1:3022 GUAVA ST
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33916-1910
Practice Address - Country:US
Practice Address - Phone:239-295-1803
Practice Address - Fax:239-939-7731
Is Sole Proprietor?:Yes
Enumeration Date:2022-10-18
Last Update Date:2022-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCNA321992376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
0000OtherN/A