Healthcare Provider Details

I. General information

NPI: 1932297876
Provider Name (Legal Business Name): KATHLEEN GLASS MS, CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/10/2006
Last Update Date: 03/20/2023
Certification Date: 03/20/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

187 MILLBURN AVE
MILLBURN NJ
07041-1847
US

IV. Provider business mailing address

40 BLAZIER RD
WARREN NJ
07059-6929
US

V. Phone/Fax

Practice location:
  • Phone: 973-467-1466
  • Fax: 973-467-1422
Mailing address:
  • Phone: 732-560-3890
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number26NR12327000
License Number StateNJ
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberAPRN9479375
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: