Provider Demographics
NPI:1619629243
Name:GREENWAY, MALLORIE BOSWELL (PA)
Entity type:Individual
Prefix:
First Name:MALLORIE
Middle Name:BOSWELL
Last Name:GREENWAY
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:MALLORIE
Other - Middle Name:LEANNE
Other - Last Name:BOSWELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 23321
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10087-4321
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2700 MAY RIVER XING STE 100
Practice Address - Street 2:
Practice Address - City:BLUFFTON
Practice Address - State:SC
Practice Address - Zip Code:29910-9732
Practice Address - Country:US
Practice Address - Phone:843-985-2520
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-01-25
Last Update Date:2024-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN4904OtherTENNESSEE DEPARTMENT OF HEALTH