Provider Demographics
NPI:1013417435
Name:PHILLIPS, GLENDA RENEE (APRN)
Entity Type:Individual
Prefix:
First Name:GLENDA
Middle Name:RENEE
Last Name:PHILLIPS
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 355
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40201-0355
Mailing Address - Country:US
Mailing Address - Phone:502-262-8956
Mailing Address - Fax:
Practice Address - Street 1:101 E MAIN ST
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40202-1349
Practice Address - Country:US
Practice Address - Phone:502-262-8956
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-13
Last Update Date:2018-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3009615363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily