Provider Demographics
NPI:1710233465
Name:GLENN, NATHAN OWEN (PTA)
Entity Type:Individual
Prefix:MR
First Name:NATHAN
Middle Name:OWEN
Last Name:GLENN
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3034 FOLSOM RD
Mailing Address - Street 2:
Mailing Address - City:MIMS
Mailing Address - State:FL
Mailing Address - Zip Code:32754-2911
Mailing Address - Country:US
Mailing Address - Phone:828-558-1388
Mailing Address - Fax:
Practice Address - Street 1:3034 FOLSOM RD
Practice Address - Street 2:
Practice Address - City:MIMS
Practice Address - State:FL
Practice Address - Zip Code:32754-2911
Practice Address - Country:US
Practice Address - Phone:828-558-1388
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-07-31
Last Update Date:2020-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL20768225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant