Healthcare Provider Details

I. General information

NPI: 1205838893
Provider Name (Legal Business Name): CAROL ANN GLASCOCK APNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MS. CAROL ANN HEARN

II. Dates (important events)

Enumeration Date: 08/12/2005
Last Update Date: 08/27/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

723 STATION XING
WATERLOO IL
62298-1886
US

IV. Provider business mailing address

723 STATION XING
WATERLOO IL
62298-1886
US

V. Phone/Fax

Practice location:
  • Phone: 618-939-1551
  • Fax: 618-939-1553
Mailing address:
  • Phone: 618-939-1551
  • Fax: 618-939-1553

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number209-000-156
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: