Provider Demographics
NPI:1659601649
Name:GLENN, KIMBERLEY (PA)
Entity Type:Individual
Prefix:
First Name:KIMBERLEY
Middle Name:
Last Name:GLENN
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Gender:F
Credentials:PA
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Mailing Address - Street 1:960 WOODSTOCK PKWY
Mailing Address - Street 2:SUITE 300
Mailing Address - City:WOODSTOCK
Mailing Address - State:GA
Mailing Address - Zip Code:30188-4866
Mailing Address - Country:US
Mailing Address - Phone:770-517-2145
Mailing Address - Fax:770-517-2147
Practice Address - Street 1:960 WOODSTOCK PKWY
Practice Address - Street 2:SUITE 300
Practice Address - City:WOODSTOCK
Practice Address - State:GA
Practice Address - Zip Code:30188-4866
Practice Address - Country:US
Practice Address - Phone:770-517-2145
Practice Address - Fax:770-517-2147
Is Sole Proprietor?:Yes
Enumeration Date:2010-01-13
Last Update Date:2017-01-10
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Provider Licenses
StateLicense IDTaxonomies
NY013821363A00000X
GA007388363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant