Healthcare Provider Details

I. General information

NPI: 1821371717
Provider Name (Legal Business Name): GLENDORA BOLAR JAMISON CRNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/27/2011
Last Update Date: 09/27/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1303 DR MARTIN L KING JR AVE
MOBILE AL
36603-5341
US

IV. Provider business mailing address

PO BOX 2048
MOBILE AL
36652-2048
US

V. Phone/Fax

Practice location:
  • Phone: 251-432-4117
  • Fax: 251-964-4012
Mailing address:
  • Phone: 251-432-4117
  • Fax: 251-964-4012

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number1-042513
License Number StateAL
# 2
Primary TaxonomyN
Taxonomy Code363LC1500X
TaxonomyCommunity Health Nurse Practitioner
License Number1-042513
License Number StateAL
# 3
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number1-042513
License Number StateAL
# 4
Primary TaxonomyN
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number1-042513
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: