Healthcare Provider Details

I. General information

NPI: 1609271303
Provider Name (Legal Business Name): KANISHA RENEE GREEN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/24/2014
Last Update Date: 07/18/2023
Certification Date: 07/18/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3840 ROSIN CT
SACRAMENTO CA
95834-1639
US

IV. Provider business mailing address

3840 ROSIN CT
SACRAMENTO CA
95834-1639
US

V. Phone/Fax

Practice location:
  • Phone: 916-230-2748
  • Fax:
Mailing address:
  • Phone: 916-230-2748
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateNULL
# 3
Primary TaxonomyY
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License NumberMPSS-MWBXCL
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: