Provider Demographics
NPI:1790467686
Name:GLAZE, TERESA CAROL
Entity Type:Individual
Prefix:DR
First Name:TERESA
Middle Name:CAROL
Last Name:GLAZE
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 1:4805 IBARRA LN
Mailing Address - Street 2:
Mailing Address - City:LEAGUE CITY
Mailing Address - State:TX
Mailing Address - Zip Code:77573-6866
Mailing Address - Country:US
Mailing Address - Phone:404-234-1889
Mailing Address - Fax:
Practice Address - Street 1:4805 IBARRA LN
Practice Address - Street 2:
Practice Address - City:LEAGUE CITY
Practice Address - State:TX
Practice Address - Zip Code:77573-6866
Practice Address - Country:US
Practice Address - Phone:404-234-1889
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-01
Last Update Date:2023-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX867616163WL0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WL0100XNursing Service ProvidersRegistered NurseLactation Consultant