Healthcare Provider Details

I. General information

NPI: 1427216795
Provider Name (Legal Business Name): GLENNIE ZOE KERTES RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/23/2008
Last Update Date: 05/23/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 W HOSPITAL RD EISENHOWER ARMY MEDICAL CENTER
FORT GORDON GA
30905-5741
US

IV. Provider business mailing address

300 W HOSPITAL RD EISENHOWER ARMY MEDICAL CENTER
FORT GORDON GA
30905-5741
US

V. Phone/Fax

Practice location:
  • Phone: 706-787-8622
  • Fax:
Mailing address:
  • Phone: 706-787-8622
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP2201X
TaxonomyAmbulatory Care Registered Nurse
License NumberR147275
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: