Healthcare Provider Details

I. General information

NPI: 1205479961
Provider Name (Legal Business Name): MYRANDA GREENWOOD NP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/24/2019
Last Update Date: 05/06/2026
Certification Date: 05/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

363 N WEST ST
OLNEY IL
62450-1160
US

IV. Provider business mailing address

363 N WEST ST
OLNEY IL
62450-1160
US

V. Phone/Fax

Practice location:
  • Phone: 618-392-1140
  • Fax: 618-392-4778
Mailing address:
  • Phone: 618-392-1140
  • Fax: 618-392-4778

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number209020264
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: