Provider Demographics
NPI:1871581595
Name:GREEN, KELLY ALISSA (PHARMD, PA-C)
Entity type:Individual
Prefix:DR
First Name:KELLY
Middle Name:ALISSA
Last Name:GREEN
Suffix:
Gender:
Credentials:PHARMD, PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:7566 N LA CHOLLA BLVD STE A
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85741-2307
Mailing Address - Country:US
Mailing Address - Phone:520-742-4139
Mailing Address - Fax:
Practice Address - Street 1:1295 N. MARTIN ROOM B308
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85712
Practice Address - Country:US
Practice Address - Phone:520-626-6016
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-10-06
Last Update Date:2025-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ125141835P1200X
363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No1835P1200XPharmacy Service ProvidersPharmacistPharmacotherapy