Provider Demographics
NPI:1154909463
Name:GLENN-MADDEN, CONSTANCE N
Entity type:Individual
Prefix:
First Name:CONSTANCE
Middle Name:N
Last Name:GLENN-MADDEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1392 BUCKINGHAM CT
Mailing Address - Street 2:
Mailing Address - City:HAMPTON
Mailing Address - State:GA
Mailing Address - Zip Code:30228-3254
Mailing Address - Country:US
Mailing Address - Phone:470-723-2943
Mailing Address - Fax:
Practice Address - Street 1:2250 MARIETTA BLVD
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30318
Practice Address - Country:US
Practice Address - Phone:470-723-2943
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-30
Last Update Date:2021-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACO1191891744P3200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1744P3200XOther Service ProvidersSpecialistProsthetics Case ManagementGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GACO119189OtherSPECIALIST