Provider Demographics
NPI:1558045294
Name:GREENWOOD, MYLAYSIA
Entity Type:Individual
Prefix:
First Name:MYLAYSIA
Middle Name:
Last Name:GREENWOOD
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 1:10100 TRINITY PKWY STE 100
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95219-7239
Mailing Address - Country:US
Mailing Address - Phone:209-953-3700
Mailing Address - Fax:209-953-9199
Practice Address - Street 1:430 N PILGRIM ST
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95205-4428
Practice Address - Country:US
Practice Address - Phone:209-466-0853
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-13
Last Update Date:2024-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No172V00000XOther Service ProvidersCommunity Health Worker