Provider Demographics
NPI:1285458455
Name:GLASS, KYLEIGH (RDN)
Entity type:Individual
Prefix:
First Name:KYLEIGH
Middle Name:
Last Name:GLASS
Suffix:
Gender:F
Credentials:RDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:42 LEE ROAD 179
Mailing Address - Street 2:
Mailing Address - City:MARIANNA
Mailing Address - State:AR
Mailing Address - Zip Code:72360-7885
Mailing Address - Country:US
Mailing Address - Phone:870-514-8764
Mailing Address - Fax:
Practice Address - Street 1:42 LEE ROAD 179
Practice Address - Street 2:
Practice Address - City:MARIANNA
Practice Address - State:AR
Practice Address - Zip Code:72360-7885
Practice Address - Country:US
Practice Address - Phone:870-514-8764
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-11-13
Last Update Date:2024-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXDT91325133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered