Healthcare Provider Details

I. General information

NPI: 1831195536
Provider Name (Legal Business Name): GAYLA B. GLENN R.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/27/2005
Last Update Date: 11/19/2010
Certification Date:
Deactivation Date: 07/17/2007
Reactivation Date: 11/12/2010

III. Provider practice location address

117 S 11TH AVE
LAUREL MS
39440-4312
US

IV. Provider business mailing address

117 S 11TH AVE
LAUREL MS
39440-4312
US

V. Phone/Fax

Practice location:
  • Phone: 601-425-3033
  • Fax: 601-422-0431
Mailing address:
  • Phone: 601-425-3033
  • Fax: 601-422-0431

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberD0697
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: