Provider Demographics
NPI:1699210831
Name:GLENN, LISA
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:GLENN
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 1:330 WOODBINE ST
Mailing Address - Street 2:
Mailing Address - City:HARRISBURG
Mailing Address - State:PA
Mailing Address - Zip Code:17110-1857
Mailing Address - Country:US
Mailing Address - Phone:717-891-4188
Mailing Address - Fax:
Practice Address - Street 1:330 WOODBINE ST
Practice Address - Street 2:
Practice Address - City:HARRISBURG
Practice Address - State:PA
Practice Address - Zip Code:17110-1857
Practice Address - Country:US
Practice Address - Phone:717-891-4188
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-12-26
Last Update Date:2016-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program