Provider Demographics
NPI:1598081960
Name:GLYNN, KIMBERLY ROSE
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:ROSE
Last Name:GLYNN
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 1:11750 W ZERO RD
Mailing Address - Street 2:
Mailing Address - City:CASPER
Mailing Address - State:WY
Mailing Address - Zip Code:82604-9540
Mailing Address - Country:US
Mailing Address - Phone:307-247-9749
Mailing Address - Fax:
Practice Address - Street 1:11750 W ZERO RD
Practice Address - Street 2:
Practice Address - City:CASPER
Practice Address - State:WY
Practice Address - Zip Code:82604-9540
Practice Address - Country:US
Practice Address - Phone:307-247-9749
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-04-10
Last Update Date:2010-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251C00000XAgenciesDay Training, Developmentally Disabled Services