MEDICARE: KANDASHA GLENN

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	163W00000X	Registered Nurse	RN282685	GA

General Provider Information

NPI Number	:	1437012333
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KANDASHA GLENN

Provider Business Mailing Address
First Line	:	4002 CREST RIDGE DR
Second Line	:
City	:	EAST POINT
State	:	GA
Zip	:	30344-8123
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	4002 CREST RIDGE DR
Second Line	:
City	:	EAST POINT
State	:	GA
Zip	:	30344-8123
Country	:	US
Telephone Number	:	470-528-7472
Fax Number	:

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

Provider Enumeration Date	:	12/08/2025
Last Update Date	:	12/08/2025

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Directions to “ KANDASHA GLENN ” Practice Location

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