Provider Demographics
NPI:1720133747
Name:WOMBLE, GLEN CURTIS (CRNFA)
Entity Type:Individual
Prefix:MR
First Name:GLEN
Middle Name:CURTIS
Last Name:WOMBLE
Suffix:
Gender:M
Credentials:CRNFA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4740 SMITHFIELD
Mailing Address - Street 2:
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32934-7864
Mailing Address - Country:US
Mailing Address - Phone:321-242-8415
Mailing Address - Fax:321-242-8415
Practice Address - Street 1:4740 SMITHFIELD
Practice Address - Street 2:
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32934-7864
Practice Address - Country:US
Practice Address - Phone:321-288-5605
Practice Address - Fax:321-242-8415
Is Sole Proprietor?:No
Enumeration Date:2007-01-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRN3180082163WR0006X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WR0006XNursing Service ProvidersRegistered NurseRegistered Nurse First Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLY100BOtherBCBS PROVIDER NUMBER