Provider Demographics
NPI:1891799250
Name:PINKHAM, GLENDA J (CNM)
Entity Type:Individual
Prefix:
First Name:GLENDA
Middle Name:J
Last Name:PINKHAM
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:701 HEWITT BLVD
Mailing Address - Street 2:
Mailing Address - City:RED WING
Mailing Address - State:MN
Mailing Address - Zip Code:55066-2848
Mailing Address - Country:US
Mailing Address - Phone:651-267-5000
Mailing Address - Fax:
Practice Address - Street 1:701 HEWITT BLVD
Practice Address - Street 2:
Practice Address - City:RED WING
Practice Address - State:MN
Practice Address - Zip Code:55066
Practice Address - Country:US
Practice Address - Phone:651-267-5000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-06-13
Last Update Date:2019-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI113280367A00000X
MN2291435367A00000X
MN272367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI39975000Medicaid
WI39975000Medicaid
WI0430Medicare PIN