Healthcare Provider Details

I. General information

NPI: 1124717780
Provider Name (Legal Business Name): SHANIKA NICOLE GLENN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/01/2023
Last Update Date: 05/01/2023
Certification Date: 05/01/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2100 COMER AVE
COLUMBUS GA
31904-8725
US

IV. Provider business mailing address

2100 COMER AVE
COLUMBUS GA
31904-8725
US

V. Phone/Fax

Practice location:
  • Phone: 706-326-4396
  • Fax:
Mailing address:
  • Phone: 706-326-4396
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WC1500X
TaxonomyCommunity Health Registered Nurse
License NumberRN202113
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: