1740791722 NPI number — LAWANDA GLASS PMHNP

Table of content: LAWANDA GLASS PMHNP (NPI 1740791722)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1740791722 NPI number — LAWANDA GLASS PMHNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GLASS
Provider First Name:
LAWANDA
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PMHNP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1740791722
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/16/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1505
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GREENWOOD
Provider Business Mailing Address State Name:
MS
Provider Business Mailing Address Postal Code:
38935-1505
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
662-453-6211
Provider Business Mailing Address Fax Number:
662-458-2558

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
714 3RD ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CLEVELAND
Provider Business Practice Location Address State Name:
MS
Provider Business Practice Location Address Postal Code:
38732
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
662-846-2620
Provider Business Practice Location Address Fax Number:
662-846-2660
Provider Enumeration Date:
10/18/2017

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363LP0808X , with the licence number:  902444 , registered in the state of MS ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 330000014 , issued by the state of ( AL ) . This identifiers is of the category "MEDICAID".




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