MEDICARE: GLEN CHARLES NOBLES JR. NP-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	ARNP 9320777	FL

General Provider Information

NPI Number	:	1467875005
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GLEN CHARLES NOBLES JR. NP-C

Provider Business Mailing Address
First Line	:	1338 SOUTH BLVD
Second Line	:
City	:	CHIPLEY
State	:	FL
Zip	:	32428-1846
Country	:	US
Telephone Number	:	850-638-6240
Fax Number	:	850-415-5010

Provider Business Practice Location Address
First Line	:	1338 SOUTH BLVD
Second Line	:
City	:	CHIPLEY
State	:	FL
Zip	:	32428-1846
Country	:	US
Telephone Number	:	850-638-6240
Fax Number	:	850-415-5010

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

Provider Enumeration Date	:	02/03/2014
Last Update Date	:	05/06/2016

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