Healthcare Provider Details

I. General information

NPI: 1346773728
Provider Name (Legal Business Name): GLENDA ROSS L.P.N.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/04/2017
Last Update Date: 04/04/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1222 10TH ST SUITE 211
WOODWARD OK
73801-3156
US

IV. Provider business mailing address

1222 10TH ST SUITE 211
WOODWARD OK
73801-3156
US

V. Phone/Fax

Practice location:
  • Phone: 580-256-8615
  • Fax: 580-256-8609
Mailing address:
  • Phone: 580-256-8615
  • Fax: 580-256-8609

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License NumberL 0026318
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: