Provider Demographics
NPI:1841775434
Name:GLICK, LUCILLE ROSE (MSN)
Entity Type:Individual
Prefix:
First Name:LUCILLE
Middle Name:ROSE
Last Name:GLICK
Suffix:
Gender:F
Credentials:MSN
Other - Prefix:
Other - First Name:LUCILLE
Other - Middle Name:ROSE
Other - Last Name:TOWER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 2927
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97208-2927
Mailing Address - Country:US
Mailing Address - Phone:503-788-7273
Mailing Address - Fax:503-788-7285
Practice Address - Street 1:3727 NE MARTIN LUTHER KING JR BLVD
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97212-1112
Practice Address - Country:US
Practice Address - Phone:503-788-7273
Practice Address - Fax:503-788-7285
Is Sole Proprietor?:No
Enumeration Date:2018-09-28
Last Update Date:2020-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR201808695NP-PP367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500756023Medicaid