Provider Demographics
NPI:1134888050
Name:GLENN, VONITA MICHELLE
Entity type:Individual
Prefix:MRS
First Name:VONITA
Middle Name:MICHELLE
Last Name:GLENN
Suffix:
Gender:F
Credentials:
Other - Prefix:MRS
Other - First Name:VONITA
Other - Middle Name:MICHELLE
Other - Last Name:WILLIAMS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:COMMERCIAL DRIVER
Mailing Address - Street 1:666 N HOLLYWOOD ST
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38112-1814
Mailing Address - Country:US
Mailing Address - Phone:901-505-7384
Mailing Address - Fax:
Practice Address - Street 1:666 N HOLLYWOOD ST
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38112-1814
Practice Address - Country:US
Practice Address - Phone:901-505-7384
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-12-08
Last Update Date:2021-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN72791070343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)