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General NPI Number Information
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NPI Number | 1598359713
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Entity Type | Individual
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Provider Name | KELLEN JAMES GLYNN MD
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Gender | Male
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Dates
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Enumeration Date | 02/28/2021
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Last Update Date | 12/13/2023
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Provider Practice Location Address
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Address Line | 1546 6TH STREET
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City | TWENTYNINE PALMS
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State | CA
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Zip | 92277
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Country | US
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Telephone | 760-830-2621
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Fax |
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Provider Business Mailing Address
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Address Line | 1546 6TH STREET
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City | TWENTYNINE PALMS
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State | CA
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Zip | 92277
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 171000000X
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Taxonomy Name | Military Health Care Provider
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License Number | 0101276029
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License Number State | VA
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Taxonomy #2
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Taxonomy Code | 208D00000X
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Taxonomy Name | General Practice Physician
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License Number | 0101276029
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License Number State | VA
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