Healthcare Provider Details

I. General information

NPI: 1215935416
Provider Name (Legal Business Name): MISHA R. GLENDENING ARNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/12/2005
Last Update Date: 05/19/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

209 MAIN ST
EDDYVILLE KY
42038-7752
US

IV. Provider business mailing address

1380 PARADISE RD P.O. BOX 120
TILINE KY
42083-9004
US

V. Phone/Fax

Practice location:
  • Phone: 270-388-0620
  • Fax: 270-388-0604
Mailing address:
  • Phone: 270-928-3196
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number1910P
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: