Healthcare Provider Details

I. General information

NPI: 1548890874
Provider Name (Legal Business Name): KRISTINA GLASS APRN-FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/26/2020
Last Update Date: 03/02/2021
Certification Date: 03/02/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1888 BOILING SPRINGS RD
BOILING SPRINGS SC
29316-5124
US

IV. Provider business mailing address

206 GENE SAMFORD DR
LUFKIN TX
75904-3358
US

V. Phone/Fax

Practice location:
  • Phone: 864-599-0920
  • Fax:
Mailing address:
  • Phone: 936-634-3396
  • Fax: 936-632-7933

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number1024733
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: