Healthcare Provider Details

I. General information

NPI: 1255897294
Provider Name (Legal Business Name): WILLETTA T GREATHOUSE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/14/2019
Last Update Date: 08/02/2021
Certification Date: 08/02/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11460 N MERIDIAN ST
CARMEL IN
46032-4530
US

IV. Provider business mailing address

11460 N MERIDIAN ST
CARMEL IN
46032-4530
US

V. Phone/Fax

Practice location:
  • Phone: 178-052-3163
  • Fax: 317-428-1032
Mailing address:
  • Phone: 317-805-2316
  • Fax: 317-428-1032

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code247200000X
TaxonomyOther Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: