Provider Demographics
NPI:1700385077
Name:DAUGHERTY, GLENNA M (APN-CNP)
Entity Type:Individual
Prefix:
First Name:GLENNA
Middle Name:M
Last Name:DAUGHERTY
Suffix:
Gender:F
Credentials:APN-CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2650 RIDGE AVE.
Mailing Address - Street 2:EMERGENCY MEDICINE
Mailing Address - City:EVANSTON
Mailing Address - State:IL
Mailing Address - Zip Code:60201-1718
Mailing Address - Country:US
Mailing Address - Phone:847-570-2114
Mailing Address - Fax:847-570-1223
Practice Address - Street 1:2650 RIDGE AVE.
Practice Address - Street 2:EMERGENCY MEDICINE
Practice Address - City:EVANSTON
Practice Address - State:IL
Practice Address - Zip Code:60201-1718
Practice Address - Country:US
Practice Address - Phone:847-570-2114
Practice Address - Fax:847-570-1223
Is Sole Proprietor?:No
Enumeration Date:2018-02-01
Last Update Date:2020-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209.016628363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner