Provider Demographics
NPI:1740692193
Name:GREENWELL, MICAH (APRN)
Entity type:Individual
Prefix:
First Name:MICAH
Middle Name:
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:PO BOX 936
Mailing Address - Street 2:
Mailing Address - City:LONDON
Mailing Address - State:KY
Mailing Address - Zip Code:40743-0936
Mailing Address - Country:US
Mailing Address - Phone:606-330-7835
Mailing Address - Fax:502-350-1023
Practice Address - Street 1:4371 NEW SHEPHERDSVILLE RD
Practice Address - Street 2:
Practice Address - City:BARDSTOWN
Practice Address - State:KY
Practice Address - Zip Code:40004-8040
Practice Address - Country:US
Practice Address - Phone:502-350-1022
Practice Address - Fax:502-350-1023
Is Sole Proprietor?:No
Enumeration Date:2014-05-20
Last Update Date:2025-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3008513363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
KYK142940Medicare PIN