MEDICARE: CONSTANCE N GLENN-MADDEN

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	1744P3200X	Prosthetics Case Management	CO119189	GA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	CO119189	OTHER	GA	SPECIALIST

General Provider Information

NPI Number	:	1154909463
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CONSTANCE N GLENN-MADDEN

Provider Business Mailing Address
First Line	:	1392 BUCKINGHAM CT
Second Line	:
City	:	HAMPTON
State	:	GA
Zip	:	30228-3254
Country	:	US
Telephone Number	:	470-723-2943
Fax Number	:

Provider Business Practice Location Address
First Line	:	2250 MARIETTA BLVD
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30318
Country	:	US
Telephone Number	:	470-723-2943
Fax Number	:

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

Provider Enumeration Date	:	03/30/2021
Last Update Date	:	03/30/2021

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