MEDICARE: GLENDA WILBURN FNP-C

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	363LF0000X	Family Nurse Practitioner	0376885-22	TX

General Provider Information

NPI Number	:	1861650574
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GLENDA WILBURN FNP-C

Provider Business Mailing Address
First Line	:	610 STRICKLAND DR STE 340
Second Line	:
City	:	ORANGE
State	:	TX
Zip	:	77630-4788
Country	:	US
Telephone Number	:	409-670-0044
Fax Number	:	409-670-0007

Provider Business Practice Location Address
First Line	:	610 STRICKLAND DR STE 340
Second Line	:
City	:	ORANGE
State	:	TX
Zip	:	77630-4788
Country	:	US
Telephone Number	:	409-670-0044
Fax Number	:	409-670-0007

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

Provider Enumeration Date	:	05/29/2008
Last Update Date	:	05/29/2008

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