Provider Demographics
NPI:1275231862
Name:GLENN, SHAYRISS (OPTICIAN)
Entity Type:Individual
Prefix:
First Name:SHAYRISS
Middle Name:
Last Name:GLENN
Suffix:
Gender:F
Credentials:OPTICIAN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 GOLDIE RD
Mailing Address - Street 2:
Mailing Address - City:YOUNGSTOWN
Mailing Address - State:OH
Mailing Address - Zip Code:44505-1948
Mailing Address - Country:US
Mailing Address - Phone:330-759-2545
Mailing Address - Fax:
Practice Address - Street 1:200 GOLDIE RD
Practice Address - Street 2:
Practice Address - City:YOUNGSTOWN
Practice Address - State:OH
Practice Address - Zip Code:44505-1948
Practice Address - Country:US
Practice Address - Phone:330-759-2545
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-02-22
Last Update Date:2023-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHOP017463S156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician