Healthcare Provider Details

I. General information

NPI: 1225667330
Provider Name (Legal Business Name): KATHLEEN ROSE GREEN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/02/2020
Last Update Date: 04/10/2024
Certification Date: 04/10/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

601 E ROLLINS ST
ORLANDO FL
32803-1248
US

IV. Provider business mailing address

1651 PALM AVE
WINTER PARK FL
32789-1648
US

V. Phone/Fax

Practice location:
  • Phone: 407-303-5600
  • Fax:
Mailing address:
  • Phone: 321-278-3446
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberRN9378227
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberAPRN11007787
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: