Provider Demographics
NPI:1609057850
Name:GULLION, GLENDA CAROL (RN BSN)
Entity Type:Individual
Prefix:MRS
First Name:GLENDA
Middle Name:CAROL
Last Name:GULLION
Suffix:
Gender:F
Credentials:RN BSN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12021 SHEARWATER RUN
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46845-8719
Mailing Address - Country:US
Mailing Address - Phone:219-765-8058
Mailing Address - Fax:
Practice Address - Street 1:4402 E STATE BLVD
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46815-6917
Practice Address - Country:US
Practice Address - Phone:260-484-8830
Practice Address - Fax:260-483-1911
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-15
Last Update Date:2007-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28124124A163WG0000X, 163WX0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WG0000XNursing Service ProvidersRegistered NurseGeneral Practice
No163WX0200XNursing Service ProvidersRegistered NurseOncology