Provider Demographics
NPI:1518625755
Name:STANDIFER, GLYNN NORA (FNP)
Entity Type:Individual
Prefix:MRS
First Name:GLYNN
Middle Name:NORA
Last Name:STANDIFER
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:59 NOBLIN RD
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:MS
Mailing Address - Zip Code:38732-9571
Mailing Address - Country:US
Mailing Address - Phone:662-719-8640
Mailing Address - Fax:
Practice Address - Street 1:201 TIM JONES HWY
Practice Address - Street 2:
Practice Address - City:BOYLE
Practice Address - State:MS
Practice Address - Zip Code:38730
Practice Address - Country:US
Practice Address - Phone:662-719-8640
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-12-06
Last Update Date:2021-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS904501163WG0000X, 207R00000X, 261QC1500X
MS261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QC1500XAmbulatory Health Care FacilitiesClinic/CenterCommunity Health
No163WG0000XNursing Service ProvidersRegistered NurseGeneral Practice
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No261Q00000XAmbulatory Health Care FacilitiesClinic/Center