Healthcare Provider Details

I. General information

NPI: 1346398419
Provider Name (Legal Business Name): GLENDA JOHNSON RICHARDSON M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/08/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2100 3RD STREET SUITE 6
KENNER LA
70062-7600
US

IV. Provider business mailing address

43 ELWOOD DR.
DESTREHAN LA
70047-3703
US

V. Phone/Fax

Practice location:
  • Phone: 566-125-1044
  • Fax: 504-466-2014
Mailing address:
  • Phone: 504-466-1251
  • Fax: 504-466-2014

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number014496
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: