Healthcare Provider Details

I. General information

NPI: 1548872344
Provider Name (Legal Business Name): SHELBY LEA GLYNN PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/21/2020
Last Update Date: 01/10/2022
Certification Date: 01/09/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1700 CENTER ST
MOBILE AL
36604-3301
US

IV. Provider business mailing address

PO BOX 746450
ATLANTA GA
30374-6450
US

V. Phone/Fax

Practice location:
  • Phone: 251-415-1546
  • Fax: 251-415-1026
Mailing address:
  • Phone: 251-434-3626
  • Fax: 251-445-2464

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA.1875
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: