Provider Demographics
NPI:1013954338
Name:GLENN, STEFANIE MARIE (CRNP)
Entity Type:Individual
Prefix:
First Name:STEFANIE
Middle Name:MARIE
Last Name:GLENN
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10 CENTER DRIVE MSC 1450
Mailing Address - Street 2:B10 CRC RM 5-5750
Mailing Address - City:BETHESDA
Mailing Address - State:MD
Mailing Address - Zip Code:20792-1268
Mailing Address - Country:US
Mailing Address - Phone:301-451-9946
Mailing Address - Fax:301-451-6989
Practice Address - Street 1:4940 EASTERN AVE
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21224-2735
Practice Address - Country:US
Practice Address - Phone:410-550-5633
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-02
Last Update Date:2010-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR135489363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD402638100Medicaid
MD402638100Medicaid
MDKR65G734Medicare ID - Type Unspecified