Basic Information
| Provider Information | |||||||||
| NPI: | 1205498268 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CLINE | ||||||||
| FirstName: | GLENN | ||||||||
| MiddleName: | CHRISTOPHER | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | APRN, FNP-BC | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 1520 W 6TH AVE APT 19 | ||||||||
| Address2: | |||||||||
| City: | COLUMBUS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 432122469 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6142713081 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 701 TECH CENTER DR | ||||||||
| Address2: | |||||||||
| City: | GAHANNA | ||||||||
| State: | OH | ||||||||
| PostalCode: | 432301987 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 1439626846 | ||||||||
| FaxNumber: | 6143962480 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/30/2019 | ||||||||
| LastUpdateDate: | 04/25/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 04/25/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | APRN.CNP.024927 | OH | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.