Provider Demographics
NPI:1023106408
Name:WINNIE, GLENNA B (MD)
Entity type:Individual
Prefix:
First Name:GLENNA
Middle Name:B
Last Name:WINNIE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2730-B PROSPERITY AVENUE
Mailing Address - Street 2:
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22031
Mailing Address - Country:US
Mailing Address - Phone:703-289-1400
Mailing Address - Fax:703-289-1414
Practice Address - Street 1:205 E. HIRST ROAD
Practice Address - Street 2:SUITE 303
Practice Address - City:PURCELLVILLE
Practice Address - State:VA
Practice Address - Zip Code:20132
Practice Address - Country:US
Practice Address - Phone:703-226-2290
Practice Address - Fax:703-289-1414
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-10
Last Update Date:2009-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCMD341682080P0214X
VA01012346612080S0012X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080S0012XAllopathic & Osteopathic PhysiciansPediatricsSleep Medicine
No2080P0214XAllopathic & Osteopathic PhysiciansPediatricsPediatric Pulmonology
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA6739989Medicaid
DC565500501Medicaid
DC034817300Medicaid
DC0885OtherCAREFIRST
011822C95Medicare ID - Type Unspecified
DC565500501Medicaid