Provider Demographics
NPI:1730689464
Name:WALDRUM, GLENDA KATHRYN (KATHY) (LVN/LPN)
Entity type:Individual
Prefix:
First Name:GLENDA
Middle Name:KATHRYN (KATHY)
Last Name:WALDRUM
Suffix:
Gender:F
Credentials:LVN/LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:308 COUNTY ROAD 1927
Mailing Address - Street 2:
Mailing Address - City:MT PLEASANT
Mailing Address - State:TX
Mailing Address - Zip Code:75455-8676
Mailing Address - Country:US
Mailing Address - Phone:903-285-9694
Mailing Address - Fax:
Practice Address - Street 1:308 COUNTY ROAD 1927
Practice Address - Street 2:
Practice Address - City:MT PLEASANT
Practice Address - State:TX
Practice Address - Zip Code:75455-8676
Practice Address - Country:US
Practice Address - Phone:903-285-9694
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-19
Last Update Date:2018-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX316852164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse