Provider Demographics
NPI:1194012005
Name:GREENLY, TAMAR (PMHNP)
Entity Type:Individual
Prefix:
First Name:TAMAR
Middle Name:
Last Name:GREENLY
Suffix:
Gender:F
Credentials:PMHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:202 E EARLL DR STE 200
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85012-2647
Mailing Address - Country:US
Mailing Address - Phone:602-808-2800
Mailing Address - Fax:602-808-2799
Practice Address - Street 1:4451 E OAK ST
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85008-2410
Practice Address - Country:US
Practice Address - Phone:602-599-5434
Practice Address - Fax:602-599-5734
Is Sole Proprietor?:No
Enumeration Date:2011-06-30
Last Update Date:2017-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZAP8308363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ011587Medicaid
KY2437681OtherCOVENTRY CARES
KY760358OtherWELLCARE
KY7100171820Medicaid
KY10006860OtherKY COOPERATIVE
KY183476OtherMEDICARE A GROUP
KY000000790877OtherANTHEM