Healthcare Provider Details

I. General information

NPI: 1689241309
Provider Name (Legal Business Name): AMY JO GLASCO FNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/10/2021
Last Update Date: 10/06/2025
Certification Date: 10/06/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

409 W OAK ST
CARBONDALE IL
62901-1464
US

IV. Provider business mailing address

PO BOX 3988
CARBONDALE IL
62902-3988
US

V. Phone/Fax

Practice location:
  • Phone: 618-529-4455
  • Fax: 618-351-1287
Mailing address:
  • Phone: 618-457-5200
  • Fax: 618-969-8416

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number209023355
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number209023355
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: