Provider Demographics
NPI:1407479702
Name:GLASS, HEATHER LYNN (APRN)
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:LYNN
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 1:3030 CUMMINGS AVE
Mailing Address - Street 2:
Mailing Address - City:TALLAHASSEE
Mailing Address - State:FL
Mailing Address - Zip Code:32311-3738
Mailing Address - Country:US
Mailing Address - Phone:352-817-2247
Mailing Address - Fax:
Practice Address - Street 1:7755 CENTER AVE STE 630
Practice Address - Street 2:
Practice Address - City:HUNTINGTON BEACH
Practice Address - State:CA
Practice Address - Zip Code:92647-9152
Practice Address - Country:US
Practice Address - Phone:657-237-2450
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-20
Last Update Date:2022-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11007189363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily