Provider Demographics
NPI:1841854502
Name:GLENN-REESE, LAQUINTA JAMETTE
Entity type:Individual
Prefix:MRS
First Name:LAQUINTA
Middle Name:JAMETTE
Last Name:GLENN-REESE
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:PO BOX 743904
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-3904
Mailing Address - Country:US
Mailing Address - Phone:803-296-7320
Mailing Address - Fax:803-296-7330
Practice Address - Street 1:6 RICHLAND MEDICAL PARK DR STE 2100
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29203-6864
Practice Address - Country:US
Practice Address - Phone:803-434-2762
Practice Address - Fax:803-434-2713
Is Sole Proprietor?:No
Enumeration Date:2019-04-29
Last Update Date:2021-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC21845363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCNP5950Medicaid