Provider Demographics
NPI:1245576834
Name:GLISSON, REGINA B (APN-C)
Entity type:Individual
Prefix:MS
First Name:REGINA
Middle Name:B
Last Name:GLISSON
Suffix:
Gender:F
Credentials:APN-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2 ALFRED CT
Mailing Address - Street 2:
Mailing Address - City:NEPTUNE
Mailing Address - State:NJ
Mailing Address - Zip Code:07753-2822
Mailing Address - Country:US
Mailing Address - Phone:732-858-4351
Mailing Address - Fax:
Practice Address - Street 1:645 NEPTUNE BLVD
Practice Address - Street 2:
Practice Address - City:NEPTUNE
Practice Address - State:NJ
Practice Address - Zip Code:07753-4118
Practice Address - Country:US
Practice Address - Phone:732-858-4351
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-12-31
Last Update Date:2023-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NJ00412300363LA2200X, 363L00000X
NYF310694-01363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Single Specialty
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult HealthGroup - Single Specialty