Provider Demographics
NPI:1760772198
Name:GLENN, KATHLEEN DESTEFANO (DO)
Entity Type:Individual
Prefix:DR
First Name:KATHLEEN
Middle Name:DESTEFANO
Last Name:GLENN
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:196 W SPROUL RD
Mailing Address - Street 2:HEALTHPLEX SUITE 205
Mailing Address - City:SPRINGFIELD
Mailing Address - State:PA
Mailing Address - Zip Code:19064-2045
Mailing Address - Country:US
Mailing Address - Phone:610-604-0888
Mailing Address - Fax:
Practice Address - Street 1:196 W SPROUL RD
Practice Address - Street 2:HEALTHPLEX SUITE 205
Practice Address - City:SPRINGFIELD
Practice Address - State:PA
Practice Address - Zip Code:19064-2045
Practice Address - Country:US
Practice Address - Phone:610-604-0888
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-04-19
Last Update Date:2015-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS017291208000000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program