Provider Demographics
NPI:1831633817
Name:GLENN, CAROLINE (MED, LAT, ATC)
Entity type:Individual
Prefix:
First Name:CAROLINE
Middle Name:
Last Name:GLENN
Suffix:
Gender:F
Credentials:MED, LAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8275 FAIRHAVEN LN
Mailing Address - Street 2:
Mailing Address - City:MONTGOMERY
Mailing Address - State:AL
Mailing Address - Zip Code:36117-6316
Mailing Address - Country:US
Mailing Address - Phone:912-657-0433
Mailing Address - Fax:
Practice Address - Street 1:5345 ATLANTA HWY
Practice Address - Street 2:
Practice Address - City:MONTGOMERY
Practice Address - State:AL
Practice Address - Zip Code:36109-3323
Practice Address - Country:US
Practice Address - Phone:334-386-7151
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-12-11
Last Update Date:2016-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1842172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker