Healthcare Provider Details

I. General information

NPI: 1972280816
Provider Name (Legal Business Name): LILLY KAYA KYARTHWYN GREEN CNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: LILLY KAYA KYARTHWYN GREEN CNP

II. Dates (important events)

Enumeration Date: 07/03/2023
Last Update Date: 05/14/2025
Certification Date: 05/14/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7704 2ND ST NW STE A
ALBUQUERQUE NM
87107-6755
US

IV. Provider business mailing address

9519 TANOAN DR NE
ALBUQUERQUE NM
87111-5836
US

V. Phone/Fax

Practice location:
  • Phone: 505-873-7400
  • Fax:
Mailing address:
  • Phone: 505-913-1470
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number61512
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: