Provider Demographics
NPI:1245744960
Name:BAKANOWSKI, GRETA (APRN)
Entity Type:Individual
Prefix:
First Name:GRETA
Middle Name:
Last Name:BAKANOWSKI
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1115 BOULDERS PKWY STE 200
Mailing Address - Street 2:
Mailing Address - City:NORTH CHESTERFIELD
Mailing Address - State:VA
Mailing Address - Zip Code:23225-4067
Mailing Address - Country:US
Mailing Address - Phone:804-915-4607
Mailing Address - Fax:
Practice Address - Street 1:8200 MEADOWBRIDGE RD STE 100
Practice Address - Street 2:
Practice Address - City:MECHANICSVILLE
Practice Address - State:VA
Practice Address - Zip Code:23116-2337
Practice Address - Country:US
Practice Address - Phone:804-559-7467
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-11-17
Last Update Date:2020-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71007767A363L00000X
KY3011745363LF0000X
VA0024178628363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily