Provider Demographics
NPI:1760417778
Name:GLYNN, DONNA M (ANP)
Entity Type:Individual
Prefix:
First Name:DONNA
Middle Name:M
Last Name:GLYNN
Suffix:
Gender:F
Credentials:ANP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 CONGRESS STREET
Mailing Address - Street 2:SUITE 2G
Mailing Address - City:QUINCY
Mailing Address - State:MA
Mailing Address - Zip Code:02169
Mailing Address - Country:US
Mailing Address - Phone:617-479-4450
Mailing Address - Fax:617-479-4499
Practice Address - Street 1:500 CONGRESS STREET
Practice Address - Street 2:SUITE 26
Practice Address - City:QUINCY
Practice Address - State:MA
Practice Address - Zip Code:02169
Practice Address - Country:US
Practice Address - Phone:617-479-4450
Practice Address - Fax:617-479-4499
Is Sole Proprietor?:No
Enumeration Date:2006-07-11
Last Update Date:2009-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA147054363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0356476Medicaid
MAGX9967OtherMEDICARE PTAN #
NP0630Medicare ID - Type Unspecified
MA0356476Medicaid
NP0630Medicare UPIN