Healthcare Provider Details

I. General information

NPI: 1174618979
Provider Name (Legal Business Name): SUSAN KIMBERLY GLASS RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/04/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4815 N. ASSEMBLY STREET
SPOKANE WA
99205-6194
US

IV. Provider business mailing address

4717 S. HELENA STREET
SPOKANE WA
99223-6542
US

V. Phone/Fax

Practice location:
  • Phone: 509-434-7000
  • Fax: 509-434-7105
Mailing address:
  • Phone: 509-838-2560
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WC0200X
TaxonomyCritical Care Medicine Registered Nurse
License NumberRN00064581
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: