Provider Demographics
NPI:1720116387
Name:GREEN, KRISTEN HILLARY (OD)
Entity Type:Individual
Prefix:
First Name:KRISTEN
Middle Name:HILLARY
Last Name:GREEN
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:228 RAMONA AVE
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84115-2115
Mailing Address - Country:US
Mailing Address - Phone:801-661-8759
Mailing Address - Fax:
Practice Address - Street 1:7025 PARK CENTRE DR
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84121-6619
Practice Address - Country:US
Practice Address - Phone:801-233-9334
Practice Address - Fax:801-233-9325
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT2774694-9934152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist