Healthcare Provider Details

I. General information

NPI: 1932334257
Provider Name (Legal Business Name): GLENDA FAY WILLIS RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/18/2009
Last Update Date: 05/18/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

403 E G ST
ELIZABETHTON TN
37643-3223
US

IV. Provider business mailing address

403 E G ST
ELIZABETHTON TN
37643-3223
US

V. Phone/Fax

Practice location:
  • Phone: 423-543-2521
  • Fax: 423-543-7348
Mailing address:
  • Phone: 423-543-2521
  • Fax: 423-543-7348

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WC1500X
TaxonomyCommunity Health Registered Nurse
License NumberRN147369
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: