Provider Demographics
NPI:1184202327
Name:GLASS, CHARITY (NP)
Entity Type:Individual
Prefix:
First Name:CHARITY
Middle Name:
Last Name:GLASS
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:942 COMMONWEALTH BLVD
Mailing Address - Street 2:
Mailing Address - City:TUPELO
Mailing Address - State:MS
Mailing Address - Zip Code:38804-9762
Mailing Address - Country:US
Mailing Address - Phone:662-620-0101
Mailing Address - Fax:662-620-0090
Practice Address - Street 1:942 COMMONWEALTH BLVD
Practice Address - Street 2:
Practice Address - City:TUPELO
Practice Address - State:MS
Practice Address - Zip Code:38804-9762
Practice Address - Country:US
Practice Address - Phone:662-620-0101
Practice Address - Fax:662-620-0090
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-30
Last Update Date:2023-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS904510363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics