Basic Information
| Provider Information | |||||||||
| NPI: | 1255808747 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DWYER | ||||||||
| FirstName: | MARY | ||||||||
| MiddleName: | CORDELLIA | ||||||||
| NamePrefix: | MS. | ||||||||
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| Credential: | APRN- BC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 480 HOPKINSVILLE ST | ||||||||
| Address2: | |||||||||
| City: | GREENVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 423451124 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2703385777 | ||||||||
| FaxNumber: | 2703385765 | ||||||||
| Practice Location | |||||||||
| Address1: | 226 HOPKINSVILLE ST | ||||||||
| Address2: | |||||||||
| City: | GREENVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 423451214 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2703773077 | ||||||||
| FaxNumber: | 2703773002 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/01/2018 | ||||||||
| LastUpdateDate: | 03/31/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/31/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LP0808X | 3012846 | KY | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health |
No ID Information.