Provider Demographics
NPI:1891043212
Name:ENSWEILER, GLENDA (NP)
Entity Type:Individual
Prefix:
First Name:GLENDA
Middle Name:
Last Name:ENSWEILER
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:707 CEDAR ST STE 405
Mailing Address - Street 2:
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46617-2059
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1025 WIDENER LN
Practice Address - Street 2:
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46614-3242
Practice Address - Country:US
Practice Address - Phone:574-335-7600
Practice Address - Fax:574-335-0734
Is Sole Proprietor?:No
Enumeration Date:2012-08-15
Last Update Date:2023-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZRN-039913163WX0003X
AZAP5651363LF0000X
IN71006868A363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163WX0003XNursing Service ProvidersRegistered NurseObstetric, Inpatient
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN300057657Medicaid