Provider Demographics
NPI:1972280816
Name:GREEN, LILLY KAYA KYARTHWYN (CNP)
Entity type:Individual
Prefix:MS
First Name:LILLY KAYA
Middle Name:KYARTHWYN
Last Name:GREEN
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:MS
Other - First Name:LILLY KAYA
Other - Middle Name:KYARTHWYN
Other - Last Name:GREEN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:CNP
Mailing Address - Street 1:9519 TANOAN DR NE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87111-5836
Mailing Address - Country:US
Mailing Address - Phone:505-913-1470
Mailing Address - Fax:
Practice Address - Street 1:199 HIGHWAY 50
Practice Address - Street 2:
Practice Address - City:PECOS
Practice Address - State:NM
Practice Address - Zip Code:87552
Practice Address - Country:US
Practice Address - Phone:505-913-1470
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-03
Last Update Date:2024-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM61512390200000X, 363LF0000X
NM390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program