Provider Demographics
NPI:1881428969
Name:ATWELL GREENWOOD, KELLY
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:ATWELL 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 1:27 SMITHTOWN POLK BLVD
Mailing Address - Street 2:
Mailing Address - City:CENTEREACH
Mailing Address - State:NY
Mailing Address - Zip Code:11720-3248
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:112 MADISON AVE
Practice Address - Street 2:
Practice Address - City:NEW HYDE PARK
Practice Address - State:NY
Practice Address - Zip Code:11040-5229
Practice Address - Country:US
Practice Address - Phone:516-343-2668
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-08-29
Last Update Date:2024-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant