Provider Demographics
NPI:1336646793
Name:WASHINGTON, GLENDA
Entity Type:Individual
Prefix:MRS
First Name:GLENDA
Middle Name:
Last Name:WASHINGTON
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 1:107 CLEVELAND RD
Mailing Address - Street 2:
Mailing Address - City:BOYCE
Mailing Address - State:LA
Mailing Address - Zip Code:71409-9284
Mailing Address - Country:US
Mailing Address - Phone:318-793-5974
Mailing Address - Fax:318-793-8453
Practice Address - Street 1:107 CLEVELAND RD
Practice Address - Street 2:
Practice Address - City:BOYCE
Practice Address - State:LA
Practice Address - Zip Code:71409-9284
Practice Address - Country:US
Practice Address - Phone:318-793-5974
Practice Address - Fax:318-793-5223
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-11
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA2203783590261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center