Provider Demographics
NPI:1740791722
Name:GLASS, LAWANDA (PMHNP)
Entity Type:Individual
Prefix:
First Name:LAWANDA
Middle Name:
Last Name:GLASS
Suffix:
Gender:F
Credentials:PMHNP
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 1505
Mailing Address - Street 2:
Mailing Address - City:GREENWOOD
Mailing Address - State:MS
Mailing Address - Zip Code:38935-1505
Mailing Address - Country:US
Mailing Address - Phone:662-453-6211
Mailing Address - Fax:662-458-2558
Practice Address - Street 1:714 3RD ST
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:MS
Practice Address - Zip Code:38732
Practice Address - Country:US
Practice Address - Phone:662-846-2620
Practice Address - Fax:662-846-2660
Is Sole Proprietor?:No
Enumeration Date:2017-10-18
Last Update Date:2018-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS902444363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL330000014Medicaid