Healthcare Provider Details

I. General information

NPI: 1417048356
Provider Name (Legal Business Name): KIM ANDERSON GREENWOOD PNP, MS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/27/2006
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

590 S OCOTILLO AVE
BENSON AZ
85602-6405
US

IV. Provider business mailing address

489 N ARROYO BLVD
NOGALES AZ
85621-2644
US

V. Phone/Fax

Practice location:
  • Phone: 520-586-7080
  • Fax: 520-586-3163
Mailing address:
  • Phone: 520-287-4713
  • Fax: 520-287-9794

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberPNPAP0073
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: