Provider Demographics
NPI:1962019836
Name:GLOSTER, TIA DANIELLE (APRN)
Entity Type:Individual
Prefix:
First Name:TIA
Middle Name:DANIELLE
Last Name:GLOSTER
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2147
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33902-2147
Mailing Address - Country:US
Mailing Address - Phone:239-343-9560
Mailing Address - Fax:239-343-9624
Practice Address - Street 1:8925 COLONIAL CENTER DR STE 1000
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33905-7813
Practice Address - Country:US
Practice Address - Phone:239-343-9560
Practice Address - Fax:239-343-9624
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-25
Last Update Date:2021-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN11006074363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL108307000Medicaid