Provider Demographics
NPI:1013088194
Name:HORNE, GLEN ROLAND (CRNA)
Entity type:Individual
Prefix:MR
First Name:GLEN
Middle Name:ROLAND
Last Name:HORNE
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5 CALHOUN AVE
Mailing Address - Street 2:UNIT 606
Mailing Address - City:DESTIN
Mailing Address - State:FL
Mailing Address - Zip Code:32541-5509
Mailing Address - Country:US
Mailing Address - Phone:404-310-6048
Mailing Address - Fax:404-255-1831
Practice Address - Street 1:2525 DESALES AVE
Practice Address - Street 2:
Practice Address - City:CHATTANOOGA
Practice Address - State:TN
Practice Address - Zip Code:37404-1161
Practice Address - Country:US
Practice Address - Phone:423-206-5040
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-13
Last Update Date:2024-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC110691367500000X
FL9397267367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA430010318OtherTRI-CARE
GA430010318OtherRAIL ROAD MEDICARE
GA20-02624OtherUNITED HEALTHCARE
GA52159539-001OtherBLUE CROSS BLUE SHIELD
GA156961100OtherU.S. DEPT OF LABOR
GA9975585OtherUNIVERSAL HEALTHCARE
GA000521435BMedicaid
GA9975585OtherUNIVERSAL HEALTHCARE
GA52159539-001OtherBLUE CROSS BLUE SHIELD