1760772198 NPI number — DR. KATHLEEN DESTEFANO GLENN D.O.

Table of content: DR. KATHLEEN DESTEFANO GLENN D.O. (NPI 1760772198)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1760772198 NPI number — DR. KATHLEEN DESTEFANO GLENN D.O.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GLENN
Provider First Name:
KATHLEEN
Provider Middle Name:
DESTEFANO
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
D.O.
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:
1760772198
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/20/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
196 W SPROUL RD
Provider Second Line Business Mailing Address:
HEALTHPLEX SUITE 205
Provider Business Mailing Address City Name:
SPRINGFIELD
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
19064-2045
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
610-604-0888
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
196 W SPROUL RD
Provider Second Line Business Practice Location Address:
HEALTHPLEX SUITE 205
Provider Business Practice Location Address City Name:
SPRINGFIELD
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
19064-2045
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
610-604-0888
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/19/2011

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: 208000000X , with the licence number:  OS017291 , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 390200000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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





Copyright © 2007-2025 www.npivalidator.com