Provider Demographics
NPI:1821194036
Name:LIGHT, GLORIA VON ROSSUM (RN, CPNP)
Entity type:Individual
Prefix:MS
First Name:GLORIA
Middle Name:VON ROSSUM
Last Name:LIGHT
Suffix:
Gender:F
Credentials:RN, CPNP
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Other - Credentials:
Mailing Address - Street 1:4500 STUART ST
Mailing Address - Street 2:MONCRIEF ARMY HOSPITAL, ATTN: MCXL-PQ (CREDENTIALS)
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29207-5700
Mailing Address - Country:US
Mailing Address - Phone:803-751-2689
Mailing Address - Fax:
Practice Address - Street 1:4500 STUART ST
Practice Address - Street 2:MONCRIEF ARMY HOSPITAL, ATTN: MCXL-PQ (CREDENTIALS)
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29207-5700
Practice Address - Country:US
Practice Address - Phone:803-751-2689
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX243250363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAD 000Medicare UPIN