Healthcare Provider Details

I. General information

NPI: 1417475450
Provider Name (Legal Business Name): MARY GREENWALT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/30/2017
Last Update Date: 02/20/2023
Certification Date: 02/20/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1100 REID PKWY STE 215
RICHMOND IN
47374-1157
US

IV. Provider business mailing address

1100 REID PKWY
RICHMOND IN
47374-1157
US

V. Phone/Fax

Practice location:
  • Phone: 765-939-9331
  • Fax: 765-939-9314
Mailing address:
  • Phone: 765-983-3127
  • Fax: 654-983-3219

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number28145063A
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number71007479A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: