Provider Demographics
NPI:1174500037
Name:GREB, ADDIE TENNILLE (ARNP)
Entity Type:Individual
Prefix:MRS
First Name:ADDIE
Middle Name:TENNILLE
Last Name:GREB
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:310 S HILLSIDE ST
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67211-2129
Mailing Address - Country:US
Mailing Address - Phone:316-684-2838
Mailing Address - Fax:316-684-3326
Practice Address - Street 1:3460 N. RIDGE RD.
Practice Address - Street 2:SUITE 120
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67205
Practice Address - Country:US
Practice Address - Phone:316-684-2838
Practice Address - Fax:316-684-2838
Is Sole Proprietor?:No
Enumeration Date:2005-12-30
Last Update Date:2019-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS45464363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
KSP95827Medicare UPIN
KS161369Medicare ID - Type Unspecified