Healthcare Provider Details

I. General information

NPI: 1902187909
Provider Name (Legal Business Name): KIMBERLY GREEN NP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/02/2011
Last Update Date: 10/15/2025
Certification Date: 10/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

815 BROADWAY
BROOKLYN NY
11206-5318
US

IV. Provider business mailing address

815 BROADWAY
BROOKLYN NY
11206-5318
US

V. Phone/Fax

Practice location:
  • Phone: 646-614-8200
  • Fax: 646-614-8200
Mailing address:
  • Phone: 646-614-8386
  • Fax: 646-614-8200

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberF342570-1
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number6421131
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: