Healthcare Provider Details

I. General information

NPI: 1114786845
Provider Name (Legal Business Name): LAURA GLASS NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/15/2024
Last Update Date: 03/12/2026
Certification Date: 03/12/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 BRIGHTWATER DR
MYRTLE BEACH SC
29579-8275
US

IV. Provider business mailing address

1180 STONECREST BOULEVARD SUITE 101
TEGA CAY SC
29708
US

V. Phone/Fax

Practice location:
  • Phone: 803-373-9378
  • Fax:
Mailing address:
  • Phone: 803-372-8585
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number28499
License Number StateSC
# 2
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number5023682
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: