Provider Demographics
NPI:1982628798
Name:PHILLIPS, GLENDA A (CNM, ARNP)
Entity Type:Individual
Prefix:
First Name:GLENDA
Middle Name:A
Last Name:PHILLIPS
Suffix:
Gender:F
Credentials:CNM, ARNP
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 16568
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32245-6568
Mailing Address - Country:US
Mailing Address - Phone:904-472-2300
Mailing Address - Fax:904-472-2330
Practice Address - Street 1:8075 GATE PKWY W STE 305
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32216-3685
Practice Address - Country:US
Practice Address - Phone:904-296-2992
Practice Address - Fax:904-296-2993
Is Sole Proprietor?:No
Enumeration Date:2006-07-26
Last Update Date:2020-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP 893572363LX0001X, 367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
No363LX0001XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL307864700Medicaid
FL307864700Medicaid