Healthcare Provider Details

I. General information

NPI: 1124092606
Provider Name (Legal Business Name): PATRICIA E GLYNN
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 02/14/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 HIGHLAND ST STE 205
MILTON MA
02186
US

IV. Provider business mailing address

100 HIGHLAND ST STE 205
MILTON MA
02186
US

V. Phone/Fax

Practice location:
  • Phone: 617-696-2434
  • Fax: 617-696-2435
Mailing address:
  • Phone: 617-696-2434
  • Fax: 617-696-2435

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number161360
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: