Healthcare Provider Details

I. General information

NPI: 1861189961
Provider Name (Legal Business Name): LEAH GLENN REGISTERED NURSE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/19/2023
Last Update Date: 04/19/2023
Certification Date: 04/07/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21180 N 87TH AVE
PEORIA AZ
85382-6497
US

IV. Provider business mailing address

6330 W THUNDERBIRD RD
GLENDALE AZ
85306-4002
US

V. Phone/Fax

Practice location:
  • Phone: 623-412-5229
  • Fax:
Mailing address:
  • Phone: 623-487-5189
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number222704
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: