Healthcare Provider Details

I. General information

NPI: 1649105685
Provider Name (Legal Business Name): CARMEN ELENA GREENWADE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/12/2026
Last Update Date: 06/12/2026
Certification Date: 06/12/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4730 LA SALLE ST
LINCOLN NE
68516-1152
US

IV. Provider business mailing address

4730 LA SALLE ST
LINCOLN NE
68516-1152
US

V. Phone/Fax

Practice location:
  • Phone: 402-601-6059
  • Fax:
Mailing address:
  • Phone: 402-601-6059
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171R00000X
TaxonomyInterpreter
License Number021695
License Number StateNE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: