Healthcare Provider Details

I. General information

NPI: 1255075586
Provider Name (Legal Business Name): NICOLETTE GLIDDEN MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/22/2022
Last Update Date: 06/30/2026
Certification Date: 06/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1125 SCHILLING BLVD E # 105TH
COLLIERVILLE TN
38017-7078
US

IV. Provider business mailing address

1125 SCHILLING BLVD E # 105TH
COLLIERVILLE TN
38017-7078
US

V. Phone/Fax

Practice location:
  • Phone: 901-624-3333
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number76967
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: