Healthcare Provider Details

I. General information

NPI: 1346902517
Provider Name (Legal Business Name): NICOLE RENEE' GLASCO FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/06/2021
Last Update Date: 11/06/2024
Certification Date: 11/06/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1783 TROUP HWY
TYLER TX
75701-5869
US

IV. Provider business mailing address

15792 COUNTY ROAD 472
TYLER TX
75706-4035
US

V. Phone/Fax

Practice location:
  • Phone: 903-595-2283
  • Fax:
Mailing address:
  • Phone: 903-293-8343
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number1141016
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: