Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 2086S0120X | Pediatric Surgery | 036-083709 | IL |
N | 2086S0120X | Pediatric Surgery | 35914 | OK |
NPI | 1235111014 |
---|---|
Provider Name | Dr. Loretto Glynn |
First Address | Fort Wayne, IN 46845-1701 |
Second Address | Mineola, NY 11501-3957 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 16/11/2005 |
Last Update Date | 28/04/2021 |