Provider Demographics
NPI:1699198291
Name:ALLEN, GLENDORA
Entity Type:Individual
Prefix:
First Name:GLENDORA
Middle Name:
Last Name:ALLEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:700 NE 13TH ST
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73104-5004
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:700 NE 13
Practice Address - Street 2:
Practice Address - City:OKC
Practice Address - State:OK
Practice Address - Zip Code:73104
Practice Address - Country:US
Practice Address - Phone:405-203-5043
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-02-03
Last Update Date:2014-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK3124283X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes283X00000XHospitalsRehabilitation Hospital