Provider Demographics
NPI:1699310631
Name:KING, GLORIA JEAN
Entity type:Individual
Prefix:
First Name:GLORIA
Middle Name:JEAN
Last Name:KING
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:PO BOX 6121
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:GA
Mailing Address - Zip Code:31706-6121
Mailing Address - Country:US
Mailing Address - Phone:229-344-2846
Mailing Address - Fax:
Practice Address - Street 1:707 BARKLEY BLVD
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:GA
Practice Address - Zip Code:31705-1207
Practice Address - Country:US
Practice Address - Phone:229-344-2846
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-11-13
Last Update Date:2019-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor