Provider Demographics
NPI:1568539211
Name:GLASS, JANETTE ANDREA (NP)
Entity Type:Individual
Prefix:
First Name:JANETTE
Middle Name:ANDREA
Last Name:GLASS
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:PO BOX 160
Mailing Address - Street 2:
Mailing Address - City:CARTHAGE
Mailing Address - State:IL
Mailing Address - Zip Code:62321-0160
Mailing Address - Country:US
Mailing Address - Phone:217-357-0617
Mailing Address - Fax:217-357-0615
Practice Address - Street 1:403 S ADAMS ST
Practice Address - Street 2:SUITE 239
Practice Address - City:CARTHAGE
Practice Address - State:IL
Practice Address - Zip Code:62321-1624
Practice Address - Country:US
Practice Address - Phone:217-357-0617
Practice Address - Fax:217-357-0615
Is Sole Proprietor?:No
Enumeration Date:2006-11-29
Last Update Date:2011-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209004070363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL209004070Medicaid
IL209004070Medicaid