Healthcare Provider Details

I. General information

NPI: 1891222980
Provider Name (Legal Business Name): KRISTEN K GREENE MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/19/2017
Last Update Date: 12/21/2022
Certification Date: 10/20/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3150 ROGERS RD STE 102
WAKE FOREST NC
27587-4196
US

IV. Provider business mailing address

2406 BLUE RIDGE RD STE 100
RALEIGH NC
27607-6692
US

V. Phone/Fax

Practice location:
  • Phone: 919-453-5363
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number0101269808
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number2022-03241
License Number StateNC

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: