Provider Demographics
NPI:1588815419
Name:GLOVER, COLLEEN RAE (RD,LD)
Entity Type:Individual
Prefix:MS
First Name:COLLEEN
Middle Name:RAE
Last Name:GLOVER
Suffix:
Gender:F
Credentials:RD,LD
Other - Prefix:MS
Other - First Name:COLLEEN
Other - Middle Name:RAE
Other - Last Name:GLOVER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RD,LD
Mailing Address - Street 1:5001 N PIEDRAS ST
Mailing Address - Street 2:
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79930-4210
Mailing Address - Country:US
Mailing Address - Phone:915-564-6100
Mailing Address - Fax:
Practice Address - Street 1:5001 N PIEDRAS ST
Practice Address - Street 2:
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79930-4210
Practice Address - Country:US
Practice Address - Phone:915-564-6100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-10-09
Last Update Date:2008-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXDT03650133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered