Provider Demographics
NPI:1265027155
Name:GLENN, TINA
Entity Type:Individual
Prefix:
First Name:TINA
Middle Name:
Last Name:GLENN
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 1:221 US ROUTE 60
Mailing Address - Street 2:
Mailing Address - City:CULLODEN
Mailing Address - State:WV
Mailing Address - Zip Code:25510-7288
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:221 US ROUTE 60
Practice Address - Street 2:
Practice Address - City:CULLODEN
Practice Address - State:WV
Practice Address - Zip Code:25510-7288
Practice Address - Country:US
Practice Address - Phone:304-444-4564
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-03
Last Update Date:2021-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker