Provider Demographics
NPI:1033133780
Name:MOLLOY, GLENN JD (ARNP)
Entity Type:Individual
Prefix:MR
First Name:GLENN
Middle Name:JD
Last Name:MOLLOY
Suffix:
Gender:M
Credentials:ARNP
Other - Prefix:
Other - First Name:GLENN
Other - Middle Name:JOSEPH DOMINIC
Other - Last Name:MOLLOY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 918025
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32891-8025
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1600 SW ARCHER RD
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32610-3003
Practice Address - Country:US
Practice Address - Phone:352-392-4541
Practice Address - Fax:352-338-7116
Is Sole Proprietor?:No
Enumeration Date:2006-07-26
Last Update Date:2008-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP2709532363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
P86042Medicare UPIN
U0112 ZMedicare PIN