MEDICARE: HOLLY GLENNON RN, LMP, CERTIFIED R

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	173C00000X	Reflexologist
2	163W00000X	Registered Nurse	RN60078268	WA
3	163WM1400X	Nurse Massage Therapist (NMT)	MA60083520	WA

General Provider Information

NPI Number	:	1487980918
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	HOLLY GLENNON RN, LMP, CERTIFIED R

Provider Business Mailing Address
First Line	:	1801 W BAY DR NW STE 208B
Second Line	:
City	:	OLYMPIA
State	:	WA
Zip	:	98502-4310
Country	:	US
Telephone Number	:	360-528-0683
Fax Number	:

Provider Business Practice Location Address
First Line	:	1801 W BAY DR NW STE 208-B
Second Line	:
City	:	OLYMPIA
State	:	WA
Zip	:	98502-4310
Country	:	US
Telephone Number	:	360-528-0683
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/17/2009
Last Update Date	:	08/03/2020

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