Healthcare Provider Details

I. General information

NPI: 1124805189
Provider Name (Legal Business Name): GLENN AGAPE EDILLOR MONTERO MSN, ARN, PMHNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/13/2023
Last Update Date: 09/15/2025
Certification Date: 09/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

141 MARKET PL STE 100
FAIRVIEW HEIGHTS IL
62208-2089
US

IV. Provider business mailing address

27 OAK KNOLL PL
BELLEVILLE IL
62223-1880
US

V. Phone/Fax

Practice location:
  • Phone: 618-398-4226
  • Fax:
Mailing address:
  • Phone: 815-919-0054
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number2023062070
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number209028943
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: