MEDICARE: MRS. GLENDA CAROL GULLION RN BSN

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	163WG0000X	General Practice Registered Nurse	28124124A	IN
2	163WX0200X	Oncology Registered Nurse	28124124A	IN

General Provider Information

NPI Number	:	1609057850
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. GLENDA CAROL GULLION RN BSN

Provider Business Mailing Address
First Line	:	12021 SHEARWATER RUN
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46845-8719
Country	:	US
Telephone Number	:	219-765-8058
Fax Number	:

Provider Business Practice Location Address
First Line	:	4402 E STATE BLVD
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46815-6917
Country	:	US
Telephone Number	:	260-484-8830
Fax Number	:	260-483-1911

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

Provider Enumeration Date	:	11/15/2007
Last Update Date	:	11/15/2007

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