Provider Demographics
NPI:1326013590
Name:GLOSE, SUSAN M (ANP)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:M
Last Name:GLOSE
Suffix:
Gender:F
Credentials:ANP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 15109
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28408-5109
Mailing Address - Country:US
Mailing Address - Phone:910-392-2525
Mailing Address - Fax:910-392-2827
Practice Address - Street 1:1709 S 16TH ST STE A
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28401-6491
Practice Address - Country:US
Practice Address - Phone:910-452-8633
Practice Address - Fax:910-452-8569
Is Sole Proprietor?:No
Enumeration Date:2006-02-21
Last Update Date:2021-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF303051363LA2200X
NC5010121363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYQ08630Medicare UPIN