Healthcare Provider Details

I. General information

NPI: 1689449142
Provider Name (Legal Business Name): ANNETTE GLASS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/15/2023
Last Update Date: 11/15/2023
Certification Date: 11/15/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

32300 S. 625 RD.
GROVE OK
74344
US

IV. Provider business mailing address

31627 S 619 LN
GROVE OK
74344-5440
US

V. Phone/Fax

Practice location:
  • Phone: 918-787-2242
  • Fax: 918-674-5041
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number73-1022204
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: