MEDICARE: LEAH GLENN REGISTERED NURSE

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	163W00000X	Registered Nurse	222704	AZ

General Provider Information

NPI Number	:	1861189961
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LEAH GLENN REGISTERED NURSE

Provider Business Mailing Address
First Line	:	6330 W THUNDERBIRD RD
Second Line	:
City	:	GLENDALE
State	:	AZ
Zip	:	85306-4002
Country	:	US
Telephone Number	:	623-487-5189
Fax Number	:

Provider Business Practice Location Address
First Line	:	21180 N 87TH AVE
Second Line	:
City	:	PEORIA
State	:	AZ
Zip	:	85382-6497
Country	:	US
Telephone Number	:	623-412-5229
Fax Number	:

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

Provider Enumeration Date	:	04/19/2023
Last Update Date	:	04/19/2023

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