Provider Demographics
NPI:1255383261
Name:DALLAS, GLYNDA MAE (CNP)
Entity type:Individual
Prefix:
First Name:GLYNDA
Middle Name:MAE
Last Name:DALLAS
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2000 W 21ST ST
Mailing Address - Street 2:SUITE A-1
Mailing Address - City:CLOVIS
Mailing Address - State:NM
Mailing Address - Zip Code:88101-4087
Mailing Address - Country:US
Mailing Address - Phone:575-762-8055
Mailing Address - Fax:575-763-3351
Practice Address - Street 1:2000 W 21ST ST
Practice Address - Street 2:#A-1
Practice Address - City:CLOVIS
Practice Address - State:NM
Practice Address - Zip Code:88101-4087
Practice Address - Country:US
Practice Address - Phone:575-762-8055
Practice Address - Fax:575-763-3351
Is Sole Proprietor?:No
Enumeration Date:2006-05-17
Last Update Date:2012-02-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMR47073363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM39038Medicaid
NM39038Medicaid