Provider Demographics
NPI:1457125569
Name:GLENN-DIARRA, MARLENE KIT-BLUE (NP)
Entity Type:Individual
Prefix:
First Name:MARLENE
Middle Name:KIT-BLUE
Last Name:GLENN-DIARRA
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1656 HARLINGTON RD
Mailing Address - Street 2:
Mailing Address - City:SMYRNA
Mailing Address - State:GA
Mailing Address - Zip Code:30082-5053
Mailing Address - Country:US
Mailing Address - Phone:215-266-2560
Mailing Address - Fax:
Practice Address - Street 1:1656 HARLINGTON RD
Practice Address - Street 2:
Practice Address - City:SMYRNA
Practice Address - State:GA
Practice Address - Zip Code:30082-5053
Practice Address - Country:US
Practice Address - Phone:215-266-2560
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-11-09
Last Update Date:2023-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN264701363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily