Provider Demographics
NPI:1790441723
Name:GREENIDGE, TAWANNA
Entity Type:Individual
Prefix:
First Name:TAWANNA
Middle Name:
Last Name:GREENIDGE
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 1:1420 CLAY AVE APT 5E
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10456-1757
Mailing Address - Country:US
Mailing Address - Phone:702-337-8428
Mailing Address - Fax:
Practice Address - Street 1:1420 CLAY AVE APT 5E
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10456-1757
Practice Address - Country:US
Practice Address - Phone:702-337-8428
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-11-15
Last Update Date:2021-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY875297174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist