Healthcare Provider Details

I. General information

NPI: 1376258061
Provider Name (Legal Business Name): JONLYN DORIS GLENN FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/18/2023
Last Update Date: 05/23/2023
Certification Date: 05/23/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1400 VFW PARKWAY
BOSTON MA
02132
US

IV. Provider business mailing address

1400 VFW PARKWAY
BOSTON MA
02132
US

V. Phone/Fax

Practice location:
  • Phone: 857-203-6574
  • Fax:
Mailing address:
  • Phone: 857-203-6574
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberRN2301677
License Number StateMA
# 2
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberRN2301677
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: