Provider Demographics
NPI:1215497698
Name:RUSSELL, GLENDA K
Entity type:Individual
Prefix:
First Name:GLENDA
Middle Name:K
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6128 E 38TH ST
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74135-5832
Mailing Address - Country:US
Mailing Address - Phone:800-722-3611
Mailing Address - Fax:
Practice Address - Street 1:6128 E 38TH ST
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74135-5832
Practice Address - Country:US
Practice Address - Phone:800-722-3611
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-22
Last Update Date:2024-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK212766164W00000X
171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No164W00000XNursing Service ProvidersLicensed Practical Nurse