Provider Demographics
NPI:1518270453
Name:KLEIN, GLENDALYN (MD,BSN,RN)
Entity Type:Individual
Prefix:
First Name:GLENDALYN
Middle Name:
Last Name:KLEIN
Suffix:
Gender:F
Credentials:MD,BSN,RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:201 N CLYDE MORRIS BLVD STE 200
Mailing Address - Street 2:
Mailing Address - City:DAYTONA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32114-2765
Mailing Address - Country:US
Mailing Address - Phone:386-425-4165
Mailing Address - Fax:386-425-7545
Practice Address - Street 1:201 N CLYDE MORRIS BLVD STE 200
Practice Address - Street 2:
Practice Address - City:DAYTONA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32114-2765
Practice Address - Country:US
Practice Address - Phone:386-425-4165
Practice Address - Fax:386-425-7545
Is Sole Proprietor?:Yes
Enumeration Date:2010-07-20
Last Update Date:2021-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO194961163W00000X
FLTRN34075207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No163W00000XNursing Service ProvidersRegistered Nurse