Provider Demographics
NPI:1811215858
Name:EWING, GLORYIAN D (LMT, LPN)
Entity Type:Individual
Prefix:
First Name:GLORYIAN
Middle Name:D
Last Name:EWING
Suffix:
Gender:F
Credentials:LMT, LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8407 HERLONG RD
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32210-2327
Mailing Address - Country:US
Mailing Address - Phone:904-666-8952
Mailing Address - Fax:
Practice Address - Street 1:6501 ARLINGTON EXPY BLDG A
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32211-5779
Practice Address - Country:US
Practice Address - Phone:904-649-6084
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-05-14
Last Update Date:2023-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPN 5178499164W00000X
FLMA44439225700000X
FLMA102448225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
No164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLA25766Medicaid