MEDICARE: SHAYLONNA GLENN

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	164W00000X	Licensed Practical Nurse	4703103664	MI

General Provider Information

NPI Number	:	1760839427
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SHAYLONNA GLENN

Provider Business Mailing Address
First Line	:	8268 RIVERVIEW ST
Second Line	:
City	:	DEARBORN HEIGHTS
State	:	MI
Zip	:	48127-1414
Country	:	US
Telephone Number	:	313-974-8933
Fax Number	:

Provider Business Practice Location Address
First Line	:	8268 RIVERVIEW ST
Second Line	:
City	:	DEARBORN HEIGHTS
State	:	MI
Zip	:	48127-1414
Country	:	US
Telephone Number	:	313-974-8933
Fax Number	:

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

Provider Enumeration Date	:	05/23/2016
Last Update Date	:	05/23/2016

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