Provider Demographics
NPI:1346403326
Name:GREENWELL, ERICA C (PA)
Entity Type:Individual
Prefix:MRS
First Name:ERICA
Middle Name:C
Last Name:GREENWELL
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 21890
Mailing Address - Street 2:
Mailing Address - City:BELFAST
Mailing Address - State:ME
Mailing Address - Zip Code:04915-4115
Mailing Address - Country:US
Mailing Address - Phone:502-907-0356
Mailing Address - Fax:502-919-9780
Practice Address - Street 1:1107 CROWN POINTE DR STE 107
Practice Address - Street 2:
Practice Address - City:ELIZABETHTOWN
Practice Address - State:KY
Practice Address - Zip Code:42701-7280
Practice Address - Country:US
Practice Address - Phone:270-506-3300
Practice Address - Fax:270-506-2843
Is Sole Proprietor?:No
Enumeration Date:2008-07-09
Last Update Date:2022-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYPA874363A00000X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
11359005OtherCAQH ID
KY7100150780Medicaid
KYP01241187OtherMEDICARE RR