Provider Demographics
NPI:1891116455
Name:BARGO, GLENNA (NURSE PRACTITIONER)
Entity type:Individual
Prefix:MRS
First Name:GLENNA
Middle Name:
Last Name:BARGO
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
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 337
Mailing Address - Street 2:
Mailing Address - City:BARBOURVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40906-0337
Mailing Address - Country:US
Mailing Address - Phone:606-545-0209
Mailing Address - Fax:606-545-0289
Practice Address - Street 1:728 S US HIGHWAY 25E LOOP NUMBER 2
Practice Address - Street 2:LOOP NUMBER 2
Practice Address - City:BARBOURVILLE
Practice Address - State:KY
Practice Address - Zip Code:40906
Practice Address - Country:US
Practice Address - Phone:606-545-0209
Practice Address - Fax:606-545-0289
Is Sole Proprietor?:No
Enumeration Date:2013-12-30
Last Update Date:2014-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3008393363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily