Provider Demographics
NPI:1558788554
Name:GLENN, DELORES
Entity Type:Individual
Prefix:
First Name:DELORES
Middle Name:
Last Name:GLENN
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 1:2111 WILSON RD
Mailing Address - Street 2:
Mailing Address - City:NEWBERRY
Mailing Address - State:SC
Mailing Address - Zip Code:29108
Mailing Address - Country:US
Mailing Address - Phone:803-321-2170
Mailing Address - Fax:803-321-2300
Practice Address - Street 1:2111 WILSON RD
Practice Address - Street 2:
Practice Address - City:NEWBERRY
Practice Address - State:SC
Practice Address - Zip Code:29108-1603
Practice Address - Country:US
Practice Address - Phone:803-321-2300
Practice Address - Fax:803-321-2300
Is Sole Proprietor?:No
Enumeration Date:2014-03-27
Last Update Date:2014-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCP37952164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse