Provider Demographics
NPI:1801445994
Name:GLEN, NODEEN (AGPCNP-BC)
Entity type:Individual
Prefix:
First Name:NODEEN
Middle Name:
Last Name:GLEN
Suffix:
Gender:F
Credentials:AGPCNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:208 BLOOMFIELD AVE APT 112
Mailing Address - Street 2:
Mailing Address - City:BLOOMFIELD
Mailing Address - State:NJ
Mailing Address - Zip Code:07003-5795
Mailing Address - Country:US
Mailing Address - Phone:973-878-2343
Mailing Address - Fax:
Practice Address - Street 1:208 BLOOMFIELD AVE APT 112
Practice Address - Street 2:
Practice Address - City:BLOOMFIELD
Practice Address - State:NJ
Practice Address - Zip Code:07003-5795
Practice Address - Country:US
Practice Address - Phone:973-878-2343
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-10
Last Update Date:2019-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NR15243600363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care