Healthcare Provider Details

I. General information

NPI: 1255383261
Provider Name (Legal Business Name): GLYNDA MAE DALLAS CNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/17/2006
Last Update Date: 02/29/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2000 W 21ST ST #A-1
CLOVIS NM
88101-4087
US

IV. Provider business mailing address

2000 W 21ST ST SUITE A-1
CLOVIS NM
88101-4087
US

V. Phone/Fax

Practice location:
  • Phone: 575-762-8055
  • Fax: 575-763-3351
Mailing address:
  • Phone: 575-762-8055
  • Fax: 575-763-3351

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberR47073
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: