Healthcare Provider Details

I. General information

NPI: 1366023681
Provider Name (Legal Business Name): ASHLEY GLAZA FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/19/2021
Last Update Date: 09/03/2026
Certification Date: 09/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3041 COMMERCE DR STE B
FORT GRATIOT MI
48059-3877
US

IV. Provider business mailing address

3041 COMMERCE DR STE B
FORT GRATIOT MI
48059-3877
US

V. Phone/Fax

Practice location:
  • Phone: 810-432-0500
  • Fax: 810-432-0501
Mailing address:
  • Phone: 810-432-0500
  • Fax: 810-432-0501

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number4704307061
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: