Provider Demographics
NPI:1700990983
Name:GLENN-SNYDER, KELLY RAE (NP)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:RAE
Last Name:GLENN-SNYDER
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:RAE
Other - Last Name:GLENN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:35318 EAGLE WAY
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60678-1353
Mailing Address - Country:US
Mailing Address - Phone:317-528-4800
Mailing Address - Fax:317-865-1479
Practice Address - Street 1:3700 W 203RD ST STE 301
Practice Address - Street 2:
Practice Address - City:OLYMPIA FIELDS
Practice Address - State:IL
Practice Address - Zip Code:60461-1182
Practice Address - Country:US
Practice Address - Phone:708-379-2850
Practice Address - Fax:708-503-3810
Is Sole Proprietor?:No
Enumeration Date:2006-08-18
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL041266672363L00000X, 363LF0000X
IL209000688363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILIL5686023OtherMEDICARE PTAN
P00147725OtherR/R MEDICARE
ILIL5686023OtherMEDICARE PTAN