Provider Demographics
NPI:1639847783
Name:GLASS KITCHINER, LANETTE E
Entity type:Individual
Prefix:
First Name:LANETTE
Middle Name:E
Last Name:GLASS KITCHINER
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 1:8313 BRIXHAM CT
Mailing Address - Street 2:
Mailing Address - City:ANTELOPE
Mailing Address - State:CA
Mailing Address - Zip Code:95843-4564
Mailing Address - Country:US
Mailing Address - Phone:352-425-4782
Mailing Address - Fax:
Practice Address - Street 1:8313 BRIXHAM CT
Practice Address - Street 2:
Practice Address - City:ANTELOPE
Practice Address - State:CA
Practice Address - Zip Code:95843-4564
Practice Address - Country:US
Practice Address - Phone:352-425-4782
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-02
Last Update Date:2021-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
133N00000X, 171400000X, 174400000X
CA2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
No133N00000XDietary & Nutritional Service ProvidersNutritionist
No171400000XOther Service ProvidersHealth & Wellness Coach
No174400000XOther Service ProvidersSpecialist