Provider Demographics
NPI:1588846323
Name:GLICK, AMY L (APRN)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:L
Last Name:GLICK
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 1:420 SAYBROOK RD
Mailing Address - Street 2:STE A
Mailing Address - City:MIDDLETOWN
Mailing Address - State:CT
Mailing Address - Zip Code:06457-4747
Mailing Address - Country:US
Mailing Address - Phone:203-503-3300
Mailing Address - Fax:203-401-3352
Practice Address - Street 1:420 SAYBROOK RD STE A
Practice Address - Street 2:
Practice Address - City:MIDDLETOWN
Practice Address - State:CT
Practice Address - Zip Code:06457-4747
Practice Address - Country:US
Practice Address - Phone:860-636-2010
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-12-04
Last Update Date:2020-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT003708363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004235918Medicaid
CT004235900Medicaid
CT004128361Medicaid