Healthcare Provider Details

I. General information

NPI: 1104255470
Provider Name (Legal Business Name): GLENISE MBAH DNP, FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/06/2013
Last Update Date: 01/23/2023
Certification Date: 01/23/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10755 FALLS RD STE 260
TIMONIUM MD
21093-4520
US

IV. Provider business mailing address

11605 35TH PL
BELTSVILLE MD
20705-2709
US

V. Phone/Fax

Practice location:
  • Phone: 410-583-2955
  • Fax:
Mailing address:
  • Phone: 240-481-3318
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberR235367
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code374U00000X
TaxonomyHome Health Aide
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: