Provider Demographics
NPI:1831454750
Name:GLENN, COURTNEY LYNN (DPM)
Entity type:Individual
Prefix:
First Name:COURTNEY
Middle Name:LYNN
Last Name:GLENN
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1515 RIVER PL STE 370
Mailing Address - Street 2:
Mailing Address - City:BRASELTON
Mailing Address - State:GA
Mailing Address - Zip Code:30517-5605
Mailing Address - Country:US
Mailing Address - Phone:770-648-5040
Mailing Address - Fax:706-780-5366
Practice Address - Street 1:1515 RIVER PL STE 370
Practice Address - Street 2:
Practice Address - City:BRASELTON
Practice Address - State:GA
Practice Address - Zip Code:30517-5605
Practice Address - Country:US
Practice Address - Phone:770-648-5040
Practice Address - Fax:706-780-5366
Is Sole Proprietor?:No
Enumeration Date:2012-07-06
Last Update Date:2019-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPOD001277213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
RIRES000Medicare UPIN