Healthcare Provider Details

I. General information

NPI: 1457930497
Provider Name (Legal Business Name): STEPHANIE GLENN APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/06/2021
Last Update Date: 08/18/2026
Certification Date: 08/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

558 ATKINS BLVD
MARIANNA AR
72360-2113
US

IV. Provider business mailing address

558 ATKINS BLVD
MARIANNA AR
72360-2113
US

V. Phone/Fax

Practice location:
  • Phone: 870-298-4258
  • Fax:
Mailing address:
  • Phone: 870-295-5225
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code364SP0808X
TaxonomyPsychiatric/Mental Health Clinical Nurse Specialist
License NumberPMH08260022
License Number StateAR
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number215156
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: