Provider Demographics
NPI:1629375712
Name:LANDRY, GLENN JEROME (NP)
Entity Type:Individual
Prefix:
First Name:GLENN
Middle Name:JEROME
Last Name:LANDRY
Suffix:
Gender:M
Credentials:NP
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Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:5959 S SHERWOOD FOREST BLVD
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70816-6038
Mailing Address - Country:US
Mailing Address - Phone:225-526-0011
Mailing Address - Fax:225-765-9196
Practice Address - Street 1:4950 ESSEN LN STE 503
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70809-3738
Practice Address - Country:US
Practice Address - Phone:225-765-1737
Practice Address - Fax:225-765-1842
Is Sole Proprietor?:No
Enumeration Date:2011-02-25
Last Update Date:2020-12-29
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
LA06368363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS2434045Medicaid
LA2141040Medicaid
274780YJA2OtherMEDICARE