MEDICARE: LANORA GLAZE NURSE PRACTITIONER

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	11002161	FL

General Provider Information

NPI Number	:	1598315608
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LANORA GLAZE NURSE PRACTITIONER

Provider Business Mailing Address
First Line	:	1645 ELMHURST RD
Second Line	:
City	:	PENSACOLA
State	:	FL
Zip	:	32505-1039
Country	:	US
Telephone Number	:	850-485-1636
Fax Number	:

Provider Business Practice Location Address
First Line	:	1645 ELMHURST RD
Second Line	:
City	:	PENSACOLA
State	:	FL
Zip	:	32505-1039
Country	:	US
Telephone Number	:	850-485-1636
Fax Number	:

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

Provider Enumeration Date	:	09/19/2019
Last Update Date	:	09/19/2019

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