Provider Demographics
NPI:1871273771
Name:GREEN, KIMBERLY (CEO, DO,)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:
Last Name:GREEN
Suffix:
Gender:F
Credentials:CEO, DO,
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:323 ENFIELD RD
Mailing Address - Street 2:
Mailing Address - City:JOPPA
Mailing Address - State:MD
Mailing Address - Zip Code:21085-3747
Mailing Address - Country:US
Mailing Address - Phone:443-600-6191
Mailing Address - Fax:410-275-0501
Practice Address - Street 1:9654A BELAIR RD STE 120
Practice Address - Street 2:
Practice Address - City:NOTTINGHAM
Practice Address - State:MD
Practice Address - Zip Code:21236-1107
Practice Address - Country:US
Practice Address - Phone:410-208-8900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-25
Last Update Date:2023-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDA00111385376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide