Provider Demographics
NPI:1619629243
Name:GREENWAY, MALLORIE BOSWELL (PA)
Entity Type:Individual
Prefix:
First Name:MALLORIE
Middle Name:BOSWELL
Last Name:GREENWAY
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:MALLORIE
Other - Middle Name:LEANNE
Other - Last Name:BOSWELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1275 DICK LONAS RD UNIT 101
Mailing Address - Street 2:
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37909-1383
Mailing Address - Country:US
Mailing Address - Phone:865-584-4747
Mailing Address - Fax:865-381-1509
Practice Address - Street 1:380 W BROADWAY BLVD
Practice Address - Street 2:
Practice Address - City:JEFFERSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37760-2602
Practice Address - Country:US
Practice Address - Phone:865-475-4742
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-01-25
Last Update Date:2023-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN4904OtherTENNESSEE DEPARTMENT OF HEALTH