Provider Demographics
NPI:1275534091
Name:GLASS, LISA G (APRN)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:G
Last Name:GLASS
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3015 WILSON AVE
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40211-1969
Mailing Address - Country:US
Mailing Address - Phone:502-774-4401
Mailing Address - Fax:502-772-4783
Practice Address - Street 1:3015 WILSON AVE
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40211-1969
Practice Address - Country:US
Practice Address - Phone:502-774-4401
Practice Address - Fax:502-772-4783
Is Sole Proprietor?:No
Enumeration Date:2005-08-02
Last Update Date:2023-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3002970363LW0102X
KY2970P363LX0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health
No363LX0001XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
000000066843OtherBLUE ACCESS/BLUE PREF.
61-1708562DOtherHUMANA
KY78029709Medicaid
7719001OtherAETNA
7719001OtherAETNA