Basic Information
| Provider Information | |||||||||
| NPI: | 1609057850 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GULLION | ||||||||
| FirstName: | GLENDA | ||||||||
| MiddleName: | CAROL | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | RN BSN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 12021 SHEARWATER RUN | ||||||||
| Address2: | |||||||||
| City: | FORT WAYNE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 468458719 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2197658058 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 4402 E STATE BLVD | ||||||||
| Address2: | |||||||||
| City: | FORT WAYNE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 468156917 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2604848830 | ||||||||
| FaxNumber: | 2604831911 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/15/2007 | ||||||||
| LastUpdateDate: | 11/15/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163WG0000X | 28124124A | IN | Y | Nursing Service Providers | Registered Nurse | General Practice | 163WX0200X | 28124124A | IN | N | Nursing Service Providers | Registered Nurse | Oncology |
No ID Information.