Healthcare Provider Details

I. General information

NPI: 1073658787
Provider Name (Legal Business Name): WONDA JEAN GLASSER C.N.A.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/20/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

510 N 19TH ST LOT 48
CANON CITY CO
81212-2467
US

IV. Provider business mailing address

1460 RED CANYON RD P.O. BOX 83
CANON CITY CO
81212-8828
US

V. Phone/Fax

Practice location:
  • Phone: 719-252-6013
  • Fax:
Mailing address:
  • Phone: 719-252-6013
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code374U00000X
TaxonomyHome Health Aide
License Number513342
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: