Healthcare Provider Details

I. General information

NPI: 1659711406
Provider Name (Legal Business Name): GLENDA GAYLE PARKS RN,MSN,IBCLC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/26/2013
Last Update Date: 06/26/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

975 E 3RD ST
CHATTANOOGA TN
37403-2147
US

IV. Provider business mailing address

975 E 3RD ST
CHATTANOOGA TN
37403-2147
US

V. Phone/Fax

Practice location:
  • Phone: 423-778-6247
  • Fax: 423-778-7674
Mailing address:
  • Phone: 423-778-6247
  • Fax: 423-778-7674

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WL0100X
TaxonomyLactation Consultant (Registered Nurse)
License Number19210983
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: