Healthcare Provider Details

I. General information

NPI: 1003886722
Provider Name (Legal Business Name): PAMELA S.F. GLENN
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 01/25/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1200 LAGOON AVE
MINNEAPOLIS MN
55408-2077
US

IV. Provider business mailing address

6440 BALLANTINE CT
INVER GROVE HEIGHTS MN
55077-2163
US

V. Phone/Fax

Practice location:
  • Phone: 612-823-6300
  • Fax:
Mailing address:
  • Phone: 651-552-9454
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367A00000X
TaxonomyAdvanced Practice Midwife
License NumberR117394-9
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code367A00000X
TaxonomyAdvanced Practice Midwife
License NumberR034727
License Number StateSD
# 3
Primary TaxonomyN
Taxonomy Code367A00000X
TaxonomyAdvanced Practice Midwife
License NumberCM000036
License Number StateSD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: