Provider Demographics
NPI:1932125598
Name:REDEEMER, GLENDA MARIE (RN)
Entity Type:Individual
Prefix:
First Name:GLENDA
Middle Name:MARIE
Last Name:REDEEMER
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1101 S MAIN ST
Mailing Address - Street 2:STE 1206
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76104-4802
Mailing Address - Country:US
Mailing Address - Phone:817-321-4710
Mailing Address - Fax:817-321-5338
Practice Address - Street 1:1101 S MAIN ST
Practice Address - Street 2:STE 1206
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104-4802
Practice Address - Country:US
Practice Address - Phone:817-321-4710
Practice Address - Fax:817-321-5338
Is Sole Proprietor?:No
Enumeration Date:2006-07-15
Last Update Date:2016-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX660833163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX170938801Medicaid
TXQ10442Medicare UPIN
TXQ10442Medicare UPIN