Provider Demographics
NPI:1275536351
Name:GLISSON, SUZANNE R (NP)
Entity Type:Individual
Prefix:MS
First Name:SUZANNE
Middle Name:R
Last Name:GLISSON
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 1:508 S HABANA AVE STE 335
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33609-4186
Mailing Address - Country:US
Mailing Address - Phone:813-872-3679
Mailing Address - Fax:813-350-4095
Practice Address - Street 1:508 S HABANA AVE STE 335
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33609-4186
Practice Address - Country:US
Practice Address - Phone:813-872-3679
Practice Address - Fax:813-350-4095
Is Sole Proprietor?:No
Enumeration Date:2005-05-23
Last Update Date:2019-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP941732363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL306919200Medicaid
FLY5185ZMedicare ID - Type Unspecified
FLGC060ZMedicare PIN
FL306919200Medicaid