1508635244 NPI number — KRYSTEN ANN GREEN MSN,APRN

Table of content: KRYSTEN ANN GREEN MSN,APRN (NPI 1508635244)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1508635244 NPI number — KRYSTEN ANN GREEN MSN,APRN

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GREEN
Provider First Name:
KRYSTEN
Provider Middle Name:
ANN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MSN,APRN
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1508635244
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/02/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
902 W MAIN ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WEST FRANKFORT
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
62896-2210
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
618-937-6483
Provider Business Mailing Address Fax Number:
618-937-1440

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
800 N MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ANNA
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
62906-1665
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
618-833-4456
Provider Business Practice Location Address Fax Number:
618-833-2371
Provider Enumeration Date:
12/21/2023

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363LP0808X , with the licence number:  209029061 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)