Provider Demographics
NPI:1356131718
Name:GREENAWALT, CLARISSA MAE (PA)
Entity type:Individual
Prefix:
First Name:CLARISSA
Middle Name:MAE
Last Name:GREENAWALT
Suffix:
Gender:
Credentials:PA
Other - Prefix:
Other - First Name:CLARISSA
Other - Middle Name:MAE
Other - Last Name:TAYLOR
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:966 GRANDVIEW DR
Mailing Address - Street 2:
Mailing Address - City:OGDEN
Mailing Address - State:UT
Mailing Address - Zip Code:84403-1942
Mailing Address - Country:US
Mailing Address - Phone:801-686-6867
Mailing Address - Fax:
Practice Address - Street 1:1800 NOVELL PL
Practice Address - Street 2:
Practice Address - City:PROVO
Practice Address - State:UT
Practice Address - Zip Code:84606-6171
Practice Address - Country:US
Practice Address - Phone:801-734-6769
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-05-08
Last Update Date:2025-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program