Provider Demographics
NPI:1578707543
Name:EKANEM, GLORY DICKSON (LPN)
Entity Type:Individual
Prefix:MISS
First Name:GLORY
Middle Name:DICKSON
Last Name:EKANEM
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2774 CARROLTON CLUB CIR
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43219-3186
Mailing Address - Country:US
Mailing Address - Phone:614-598-7300
Mailing Address - Fax:
Practice Address - Street 1:2774 CARROLTON CLUB CIR
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43219-3186
Practice Address - Country:US
Practice Address - Phone:614-598-7300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-04-21
Last Update Date:2009-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPN.132989 IV164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse