Provider Demographics
NPI:1417532557
Name:GLASS, REBECCA RAE (AGPCNP-BC)
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:RAE
Last Name:GLASS
Suffix:
Gender:F
Credentials:AGPCNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10165 W 25TH AVE APT 90
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD
Mailing Address - State:CO
Mailing Address - Zip Code:80215-1457
Mailing Address - Country:US
Mailing Address - Phone:785-979-1467
Mailing Address - Fax:
Practice Address - Street 1:10165 W 25TH AVE APT 90
Practice Address - Street 2:
Practice Address - City:LAKEWOOD
Practice Address - State:CO
Practice Address - Zip Code:80215-1457
Practice Address - Country:US
Practice Address - Phone:785-979-1467
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-10
Last Update Date:2021-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COAPN.0996288-NP363LG0600X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology