Provider Demographics
NPI:1326773532
Name:GREENWALD, MIKAYLA MARIE
Entity Type:Individual
Prefix:
First Name:MIKAYLA
Middle Name:MARIE
Last Name:GREENWALD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6701 SW 34TH ST
Mailing Address - Street 2:
Mailing Address - City:LINCOLN
Mailing Address - State:NE
Mailing Address - Zip Code:68523-9133
Mailing Address - Country:US
Mailing Address - Phone:402-937-3296
Mailing Address - Fax:
Practice Address - Street 1:1111 N 102ND CT STE 200
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68114-2194
Practice Address - Country:US
Practice Address - Phone:402-502-2747
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-21
Last Update Date:2024-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE3061363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical