Provider Demographics
NPI:1598104218
Name:ENDICOTT, GLORIA YVONNE (MSN,RN,CNL, CNP)
Entity Type:Individual
Prefix:
First Name:GLORIA
Middle Name:YVONNE
Last Name:ENDICOTT
Suffix:
Gender:F
Credentials:MSN,RN,CNL, CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2582 PARK ST
Mailing Address - Street 2:
Mailing Address - City:MILLERSPORT
Mailing Address - State:OH
Mailing Address - Zip Code:43046-9033
Mailing Address - Country:US
Mailing Address - Phone:937-594-1768
Mailing Address - Fax:
Practice Address - Street 1:1810 MESQUITE AVE STE B
Practice Address - Street 2:
Practice Address - City:LAKE HAVASU CITY
Practice Address - State:AZ
Practice Address - Zip Code:86403-5886
Practice Address - Country:US
Practice Address - Phone:928-453-4600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-06-15
Last Update Date:2019-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHCOA.14569-NP363LF0000X
CANP95003184363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily