Healthcare Provider Details

I. General information

NPI: 1336646793
Provider Name (Legal Business Name): MRS. GLENDA WASHINGTON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/11/2018
Last Update Date: 06/16/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

107 CLEVELAND RD
BOYCE LA
71409-9284
US

IV. Provider business mailing address

107 CLEVELAND RD
BOYCE LA
71409-9284
US

V. Phone/Fax

Practice location:
  • Phone: 318-793-5974
  • Fax: 318-793-5223
Mailing address:
  • Phone: 318-793-5974
  • Fax: 318-793-8453

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number2203783590
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: