Provider Demographics
NPI:1538534011
Name:KEBORTZ, GLENDA D (NP)
Entity type:Individual
Prefix:
First Name:GLENDA
Middle Name:D
Last Name:KEBORTZ
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:GLENDA
Other - Middle Name:D
Other - Last Name:KAST
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2072 N COUNTY ROAD 700 W
Mailing Address - Street 2:
Mailing Address - City:RICHLAND
Mailing Address - State:IN
Mailing Address - Zip Code:47634-9480
Mailing Address - Country:US
Mailing Address - Phone:812-359-4012
Mailing Address - Fax:812-359-4481
Practice Address - Street 1:2072 N COUNTY ROAD 700 W
Practice Address - Street 2:
Practice Address - City:RICHLAND
Practice Address - State:IN
Practice Address - Zip Code:47634-9480
Practice Address - Country:US
Practice Address - Phone:812-359-4012
Practice Address - Fax:812-359-4481
Is Sole Proprietor?:No
Enumeration Date:2015-12-09
Last Update Date:2017-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71005947A363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily