Provider Demographics
NPI:1639624893
Name:BASTIN, GLENDA (RN)
Entity Type:Individual
Prefix:
First Name:GLENDA
Middle Name:
Last Name:BASTIN
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2609
Mailing Address - Street 2:108 NEW GLENDALE ROAD
Mailing Address - City:ELIZABETHTOWN
Mailing Address - State:KY
Mailing Address - Zip Code:42702-2609
Mailing Address - Country:US
Mailing Address - Phone:270-769-1601
Mailing Address - Fax:270-765-7274
Practice Address - Street 1:108 NEW GLENDALE RD
Practice Address - Street 2:
Practice Address - City:ELIZABETHTOWN
Practice Address - State:KY
Practice Address - Zip Code:42701-1023
Practice Address - Country:US
Practice Address - Phone:270-769-1601
Practice Address - Fax:270-765-7274
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-17
Last Update Date:2016-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY1045777163WC1500X, 163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WC1500XNursing Service ProvidersRegistered NurseCommunity Health
No163W00000XNursing Service ProvidersRegistered Nurse