=====================================================
General NPI Number Information
=====================================================
NPI Number | 1447291596
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MARY ANN GLICK NP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/09/2006
-----------------------------------------------------
Last Update Date | 07/18/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 306 HEMPSTEAD AVE
-----------------------------------------------------
City | MALVERNE
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11565-1201
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 516-678-0076
-----------------------------------------------------
Fax | 516-763-0981
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 306 HEMPSTEAD AVE
-----------------------------------------------------
City | MALVERNE
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11565-1201
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 516-678-0076
-----------------------------------------------------
Fax | 516-763-0981
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363L00000X
-----------------------------------------------------
Taxonomy Name | Nurse Practitioner
-----------------------------------------------------
License Number | 212311-1
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------