Basic Information
| Provider Information | |||||||||
| NPI: | 1609879782 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GREENE | ||||||||
| FirstName: | KRISTINA | ||||||||
| MiddleName: | RENAE | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3024 BUSINESS PARK CIR | ||||||||
| Address2: | |||||||||
| City: | GOODLETTSVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 370723132 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6158516033 | ||||||||
| FaxNumber: | 6152969935 | ||||||||
| Practice Location | |||||||||
| Address1: | 980 PROFESSIONAL PARK DR | ||||||||
| Address2: | SUITE A | ||||||||
| City: | CLARKSVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 370405251 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9319051001 | ||||||||
| FaxNumber: | 9319050410 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/23/2005 | ||||||||
| LastUpdateDate: | 04/30/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | PA840 | TN | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 3667492 | 05 | TN | MEDICAID | P00433226 | 01 | TN | MEDICARE RAILROAD | OTHER |