Healthcare Provider Details

I. General information

NPI: 1720859424
Provider Name (Legal Business Name): GLENNA ROSE GODFREY
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/11/2024
Last Update Date: 07/23/2026
Certification Date: 07/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1377 LOCUST AVE
FAIRMONT WV
26554-1791
US

IV. Provider business mailing address

333 VALE CIR
FAIRMONT WV
26554-6188
US

V. Phone/Fax

Practice location:
  • Phone: 855-988-2273
  • Fax:
Mailing address:
  • Phone: 304-694-5393
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number3219
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: