Provider Demographics
NPI:1831195536
Name:GLENN, GAYLA B (RD)
Entity type:Individual
Prefix:MS
First Name:GAYLA
Middle Name:B
Last Name:GLENN
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:117 S 11TH AVE
Mailing Address - Street 2:
Mailing Address - City:LAUREL
Mailing Address - State:MS
Mailing Address - Zip Code:39440-4312
Mailing Address - Country:US
Mailing Address - Phone:601-425-3033
Mailing Address - Fax:601-422-0431
Practice Address - Street 1:117 S 11TH AVE
Practice Address - Street 2:
Practice Address - City:LAUREL
Practice Address - State:MS
Practice Address - Zip Code:39440-4312
Practice Address - Country:US
Practice Address - Phone:601-425-3033
Practice Address - Fax:601-422-0431
Is Sole Proprietor?:No
Enumeration Date:2005-06-27
Last Update Date:2010-11-19
Deactivation Date:2007-07-17
Deactivation Code:
Reactivation Date:2010-11-12
Provider Licenses
StateLicense IDTaxonomies
MSD0697133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered