Provider Demographics
NPI:1477717676
Name:MACKINNON, GLENNA
Entity Type:Individual
Prefix:MS
First Name:GLENNA
Middle Name:
Last Name:MACKINNON
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 1:1642 N COAST HWY
Mailing Address - Street 2:
Mailing Address - City:NEWPORT
Mailing Address - State:OR
Mailing Address - Zip Code:97365-2357
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1642 NORTH COAST HWY
Practice Address - Street 2:
Practice Address - City:NEWPORT
Practice Address - State:OK
Practice Address - Zip Code:97405-2357
Practice Address - Country:US
Practice Address - Phone:541-574-9174
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-16
Last Update Date:2008-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR5231174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist