Provider Demographics
NPI:1770217903
Name:GLENN, MARKESIAE SYMONE (NP)
Entity Type:Individual
Prefix:
First Name:MARKESIAE
Middle Name:SYMONE
Last Name:GLENN
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7 EXECUTIVE PARK DR NE APT 2407
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30329-2271
Mailing Address - Country:US
Mailing Address - Phone:662-410-8202
Mailing Address - Fax:
Practice Address - Street 1:575 W PIKE ST
Practice Address - Street 2:
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30046-7685
Practice Address - Country:US
Practice Address - Phone:770-277-0230
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-13
Last Update Date:2022-07-15
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
GANP000689363LW0102X
MS905222363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health