Provider Demographics
NPI:1609271303
Name:GREEN, KANISHA RENEE
Entity type:Individual
Prefix:
First Name:KANISHA
Middle Name:RENEE
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 1:3840 ROSIN CT
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95834-1639
Mailing Address - Country:US
Mailing Address - Phone:916-230-2748
Mailing Address - Fax:
Practice Address - Street 1:3840 ROSIN CT
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95834-1639
Practice Address - Country:US
Practice Address - Phone:916-230-2748
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-10-24
Last Update Date:2023-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X, 172V00000X
CAMPSS-MWBXCL175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
No172V00000XOther Service ProvidersCommunity Health Worker