Basic Information
| Provider Information | |||||||||
| NPI: | 1861587024 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GREENE | ||||||||
| FirstName: | JUDITH | ||||||||
| MiddleName: | KATHRYN | ||||||||
| NamePrefix: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | GAVIGAN | ||||||||
| OtherFirstName: | JUDITH | ||||||||
| OtherMiddleName: | KATHRYN | ||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | APRN | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 10 SACHEMS TRL | ||||||||
| Address2: | PO BOX 383 | ||||||||
| City: | WEST SIMSBURY | ||||||||
| State: | CT | ||||||||
| PostalCode: | 060922525 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8606518428 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 225 HOPMEADOW ST | ||||||||
| Address2: | SUITE # 100 | ||||||||
| City: | WEATOGUE | ||||||||
| State: | CT | ||||||||
| PostalCode: | 060899782 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8606580465 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/04/2006 | ||||||||
| LastUpdateDate: | 08/30/2007 | ||||||||
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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 | 363LP0200X | 002331 | CT | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Pediatrics |
No ID Information.