Provider Demographics
NPI:1508841149
Name:GREENWELL, MARY JANE (APRN)
Entity Type:Individual
Prefix:MS
First Name:MARY
Middle Name:JANE
Last Name:GREENWELL
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 1:6801 DIXIE HWY
Mailing Address - Street 2:SUITE 130
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40258-3913
Mailing Address - Country:US
Mailing Address - Phone:502-585-2300
Mailing Address - Fax:502-584-2726
Practice Address - Street 1:250 E LIBERTY ST
Practice Address - Street 2:SUITE 202
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40202-1530
Practice Address - Country:US
Practice Address - Phone:502-585-2300
Practice Address - Fax:502-584-2726
Is Sole Proprietor?:No
Enumeration Date:2005-12-07
Last Update Date:2014-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3003885363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY78014446Medicaid
IN200506700A/BMedicaid
KY50040684OtherPASSPORT-JPG
KYK051390 (JPG)Medicare PIN
KYP75553Medicare UPIN
KY78014446Medicaid
IN195720ZMedicare PIN
KY50040684OtherPASSPORT-JPG
IN200506700A/BMedicaid