Provider Demographics
NPI:1013573955
Name:EVERSON, GLENDA LYNITA
Entity Type:Individual
Prefix:
First Name:GLENDA
Middle Name:LYNITA
Last Name:EVERSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:317 E HOBSON ST
Mailing Address - Street 2:
Mailing Address - City:SYLVESTER
Mailing Address - State:GA
Mailing Address - Zip Code:31791-3812
Mailing Address - Country:US
Mailing Address - Phone:229-272-2284
Mailing Address - Fax:
Practice Address - Street 1:317 E HOBSON ST
Practice Address - Street 2:
Practice Address - City:SYLVESTER
Practice Address - State:GA
Practice Address - Zip Code:31791-3812
Practice Address - Country:US
Practice Address - Phone:229-272-2284
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-16
Last Update Date:2019-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA054361664171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor