Provider Demographics
NPI:1861587024
Name:GREENE, JUDITH KATHRYN
Entity type:Individual
Prefix:
First Name:JUDITH
Middle Name:KATHRYN
Last Name:GREENE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JUDITH
Other - Middle Name:KATHRYN
Other - Last Name:GAVIGAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:APRN
Mailing Address - Street 1:10 SACHEMS TRL
Mailing Address - Street 2:PO BOX 383
Mailing Address - City:WEST SIMSBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06092-2525
Mailing Address - Country:US
Mailing Address - Phone:860-651-8428
Mailing Address - Fax:
Practice Address - Street 1:225 HOPMEADOW ST
Practice Address - Street 2:SUITE # 100
Practice Address - City:WEATOGUE
Practice Address - State:CT
Practice Address - Zip Code:06089-9782
Practice Address - Country:US
Practice Address - Phone:860-658-0465
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-04
Last Update Date:2007-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT002331363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics