Provider Demographics
NPI:1790410033
Name:GLAS, KELLY ANN (FNP-C)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:ANN
Last Name:GLAS
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14111 CHICARITA CREEK RD
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92128-3611
Mailing Address - Country:US
Mailing Address - Phone:858-437-2077
Mailing Address - Fax:
Practice Address - Street 1:8851 CENTER DR STE 408
Practice Address - Street 2:
Practice Address - City:LA MESA
Practice Address - State:CA
Practice Address - Zip Code:91942-3076
Practice Address - Country:US
Practice Address - Phone:619-583-1174
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-20
Last Update Date:2022-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95021834363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care