Provider Demographics
NPI:1104588227
Name:GREEN, KRISTIN ANN (FNP-C)
Entity type:Individual
Prefix:
First Name:KRISTIN
Middle Name:ANN
Last Name:GREEN
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:KRISTIN
Other - Middle Name:ANN
Other - Last Name:KETELAAR
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4601 E MCCAIN BLVD
Mailing Address - Street 2:
Mailing Address - City:NORTH LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72117-2904
Mailing Address - Country:US
Mailing Address - Phone:501-945-4200
Mailing Address - Fax:
Practice Address - Street 1:4601 E MCCAIN BLVD
Practice Address - Street 2:
Practice Address - City:NORTH LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72117-2904
Practice Address - Country:US
Practice Address - Phone:501-945-4200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-06
Last Update Date:2025-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209.023986363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily