MEDICARE: MR. JUSTIN MATTHEW GLAZE MSN, APRN, FNP-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LF0000X	Family Nurse Practitioner	APRN-NP268132	GA

General Provider Information

NPI Number	:	1144955956
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. JUSTIN MATTHEW GLAZE MSN, APRN, FNP-C

Provider Business Mailing Address
First Line	:	1107 MEMORIAL DR STE G2
Second Line	:
City	:	DALTON
State	:	GA
Zip	:	30720-8662
Country	:	US
Telephone Number	:	706-529-3245
Fax Number	:	706-272-6077

Provider Business Practice Location Address
First Line	:	1107 MEMORIAL DR STE G2
Second Line	:
City	:	DALTON
State	:	GA
Zip	:	30720-8662
Country	:	US
Telephone Number	:	706-529-3245
Fax Number	:	706-272-6077

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/18/2022
Last Update Date	:	05/07/2026

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