Basic Information
| Provider Information | |||||||||
| NPI: | 1841775434 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GLICK | ||||||||
| FirstName: | LUCILLE | ||||||||
| MiddleName: | ROSE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MSN | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | TOWER | ||||||||
| OtherFirstName: | LUCILLE | ||||||||
| OtherMiddleName: | ROSE | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 2927 | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972082927 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5037887273 | ||||||||
| FaxNumber: | 5037887285 | ||||||||
| Practice Location | |||||||||
| Address1: | 3727 NE MARTIN LUTHER KING JR BLVD | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972121112 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5037887273 | ||||||||
| FaxNumber: | 5037887285 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/28/2018 | ||||||||
| LastUpdateDate: | 05/11/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 05/11/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367A00000X | 201808695NP-PP | OR | Y | Physician Assistants & Advanced Practice Nursing Providers | Advanced Practice Midwife |
ID Information
| ID | Type | State | Issuer | Description | 500756023 | 05 | OR | MEDICAID |