Provider Demographics
NPI:1821661547
Name:GLASS, NIKKI (APRN CNP)
Entity Type:Individual
Prefix:
First Name:NIKKI
Middle Name:
Last Name:GLASS
Suffix:
Gender:F
Credentials:APRN CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:625 CLEVELAND AVE NW
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:OH
Mailing Address - Zip Code:44702-1805
Mailing Address - Country:US
Mailing Address - Phone:330-455-0374
Mailing Address - Fax:
Practice Address - Street 1:130 1ST ST NW
Practice Address - Street 2:
Practice Address - City:MASSILLON
Practice Address - State:OH
Practice Address - Zip Code:44647-5452
Practice Address - Country:US
Practice Address - Phone:330-833-0234
Practice Address - Fax:330-837-7705
Is Sole Proprietor?:No
Enumeration Date:2021-07-20
Last Update Date:2021-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHAPRN.CNP.0029590363LP0808X
OH0029520363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0459508Medicaid