Provider Demographics
NPI:1679395032
Name:WILLIAMS, GLENNA MICHEAL (PRSS)
Entity type:Individual
Prefix:
First Name:GLENNA
Middle Name:MICHEAL
Last Name:WILLIAMS
Suffix:
Gender:F
Credentials:PRSS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:904 DRY HILL RD
Mailing Address - Street 2:
Mailing Address - City:BECKLEY
Mailing Address - State:WV
Mailing Address - Zip Code:25801-2036
Mailing Address - Country:US
Mailing Address - Phone:304-860-3110
Mailing Address - Fax:
Practice Address - Street 1:3049 ROBERT C BYRD DR
Practice Address - Street 2:
Practice Address - City:BECKLEY
Practice Address - State:WV
Practice Address - Zip Code:25801-4465
Practice Address - Country:US
Practice Address - Phone:304-860-3110
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-10-28
Last Update Date:2024-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV21-909175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist