Provider Demographics
NPI:1942621883
Name:JOHN, GLENDA
Entity Type:Individual
Prefix:
First Name:GLENDA
Middle Name:
Last Name:JOHN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:242 HERZL ST APT 2
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11212-4633
Mailing Address - Country:US
Mailing Address - Phone:347-567-1294
Mailing Address - Fax:
Practice Address - Street 1:242 HERZL ST APT 2
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11212-4633
Practice Address - Country:US
Practice Address - Phone:347-567-1294
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-12-19
Last Update Date:2013-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY317042-1164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse