Healthcare Provider Details

I. General information

NPI: 1205992963
Provider Name (Legal Business Name): BETTY A GLYNN RDCD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/28/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2900 W OKLAHOMA AVE
MILWAUKEE WI
53215-4330
US

IV. Provider business mailing address

6100 W STONEHEDGE DR UNIT 331
GREENFIELD WI
53220-4635
US

V. Phone/Fax

Practice location:
  • Phone: 414-649-6942
  • Fax: 414-649-5091
Mailing address:
  • Phone: 414-282-0609
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number58-029
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: