Provider Demographics
NPI:1952109381
Name:BEENBLOSSOM, GLENDA
Entity type:Individual
Prefix:
First Name:GLENDA
Middle Name:
Last Name:BEENBLOSSOM
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11011 Q ST STE 101C
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68137-3700
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:407 W 13TH ST
Practice Address - Street 2:
Practice Address - City:COZAD
Practice Address - State:NE
Practice Address - Zip Code:69130-1418
Practice Address - Country:US
Practice Address - Phone:303-083-2569
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-03-03
Last Update Date:2025-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant