MEDICARE: MS. GLENNA MACKINNON

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	174400000X	Specialist	5231	OR

General Provider Information

NPI Number	:	1477717676
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. GLENNA MACKINNON

Provider Business Mailing Address
First Line	:	1642 N COAST HWY
Second Line	:
City	:	NEWPORT
State	:	OR
Zip	:	97365-2357
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1642 NORTH COAST HWY
Second Line	:
City	:	NEWPORT
State	:	OK
Zip	:	97405-2357
Country	:	US
Telephone Number	:	541-574-9174
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/16/2008
Last Update Date	:	07/16/2008

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Directions to “ MS. GLENNA MACKINNON ” Practice Location

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