Healthcare Provider Details

I. General information

NPI: 1679527923
Provider Name (Legal Business Name): KATHRYN J GLASS MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: KATHRYN LEONA JOHNSON

II. Dates (important events)

Enumeration Date: 05/20/2006
Last Update Date: 09/21/2026
Certification Date: 09/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

143 KENNEDY DR
MARTIN TN
38237-3309
US

IV. Provider business mailing address

143 KENNEDY DR
MARTIN TN
38237-3309
US

V. Phone/Fax

Practice location:
  • Phone: 731-587-5321
  • Fax: 731-588-5909
Mailing address:
  • Phone: 731-587-5321
  • Fax: 731-588-5909

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number38858
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: