Healthcare Provider Details

I. General information

NPI: 1972112357
Provider Name (Legal Business Name): MARIE L GLORIE NP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/30/2020
Last Update Date: 07/30/2020
Certification Date: 07/30/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

625 W MEMORIAL DR
DALLAS GA
30132-4120
US

IV. Provider business mailing address

4235 THAYER DR
POWDER SPRINGS GA
30127-5651
US

V. Phone/Fax

Practice location:
  • Phone: 678-903-5103
  • Fax:
Mailing address:
  • Phone: 404-985-0242
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License NumberRN217524
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: