Provider Demographics
NPI:1316011653
Name:MCCONNELL, GLENDA ANN (PMHNP, BC)
Entity Type:Individual
Prefix:
First Name:GLENDA
Middle Name:ANN
Last Name:MCCONNELL
Suffix:
Gender:F
Credentials:PMHNP, BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1496 BELLEVUE ST
Mailing Address - Street 2:SUITE 101
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54311-4205
Mailing Address - Country:US
Mailing Address - Phone:920-784-2644
Mailing Address - Fax:920-784-2655
Practice Address - Street 1:1496 BELLEVUE ST
Practice Address - Street 2:SUITE 101
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54311-4205
Practice Address - Country:US
Practice Address - Phone:920-784-2644
Practice Address - Fax:920-784-2655
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-20
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2515-033363LP0808X, 163WP0807X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163WP0807XNursing Service ProvidersRegistered NursePsychiatric/Mental Health, Child & Adolescent
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI2515-033OtherADVANCED PRACTICE NURSE PRESCRIBER
WI43600000Medicaid
WI391047205011OtherANTHEM BLUE CROSS
WI391047205011OtherANTHEM BLUE CROSS
WI43600000Medicaid