Healthcare Provider Details

I. General information

NPI: 1629603469
Provider Name (Legal Business Name): GLENDA DILLARD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/11/2020
Last Update Date: 03/11/2020
Certification Date: 03/11/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7405 S 39TH DR
PHOENIX AZ
85041-6002
US

IV. Provider business mailing address

3170 STILLWATER DR
PRESCOTT AZ
86305-7151
US

V. Phone/Fax

Practice location:
  • Phone: 708-813-3458
  • Fax:
Mailing address:
  • Phone: 928-777-3280
  • Fax: 928-717-1660

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: