Healthcare Provider Details

I. General information

NPI: 1164958484
Provider Name (Legal Business Name): EHREN GLECKLER
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/05/2017
Last Update Date: 06/11/2021
Certification Date: 06/11/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12 7TH ST
AUBURN GA
30011-3202
US

IV. Provider business mailing address

PO BOX 742616
ATLANTA GA
30374-2616
US

V. Phone/Fax

Practice location:
  • Phone: 770-848-9320
  • Fax:
Mailing address:
  • Phone: 770-219-8420
  • Fax: 770-219-8440

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberRN216327
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: