Healthcare Provider Details

I. General information

NPI: 1558349985
Provider Name (Legal Business Name): GLENN LEVER C.R.N.A.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/05/2006
Last Update Date: 07/16/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 PARKLAND DR
DERRY NH
03038-2746
US

IV. Provider business mailing address

PO BOX 1849
LEWISTON ME
04241-1849
US

V. Phone/Fax

Practice location:
  • Phone: 603-421-2163
  • Fax:
Mailing address:
  • Phone: 207-784-2554
  • Fax: 207-777-5363

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number029078-23-11
License Number StateNH
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number029078-23
License Number StateNH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: