Provider Demographics
NPI:1215180211
Name:LANCLOS, GLENN WILSON (FNP-C)
Entity Type:Individual
Prefix:MR
First Name:GLENN
Middle Name:WILSON
Last Name:LANCLOS
Suffix:
Gender:M
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1514 JEFFERSON HWY
Mailing Address - Street 2:
Mailing Address - City:NEW ORLEANS
Mailing Address - State:LA
Mailing Address - Zip Code:70121-2429
Mailing Address - Country:US
Mailing Address - Phone:504-842-4000
Mailing Address - Fax:
Practice Address - Street 1:1151 MARGUERITE ST
Practice Address - Street 2:
Practice Address - City:MORGAN CITY
Practice Address - State:LA
Practice Address - Zip Code:70380-1850
Practice Address - Country:US
Practice Address - Phone:985-380-2200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-11-04
Last Update Date:2021-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAAP05639363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2336720Medicaid