Provider Demographics
NPI:1780177030
Name:MIMS, EMILY GLASS
Entity type:Individual
Prefix:
First Name:EMILY
Middle Name:GLASS
Last Name:MIMS
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 1:5750A SOUTHLAND DR
Mailing Address - Street 2:
Mailing Address - City:MOBILE
Mailing Address - State:AL
Mailing Address - Zip Code:36693-3316
Mailing Address - Country:US
Mailing Address - Phone:251-450-5916
Mailing Address - Fax:
Practice Address - Street 1:9518 US HIGHWAY 231
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:AL
Practice Address - Zip Code:35132-5551
Practice Address - Country:US
Practice Address - Phone:205-319-8000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-12
Last Update Date:2020-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1-153476363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner