Basic Information
| Provider Information | |||||||||
| NPI: | 1629375712 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LANDRY | ||||||||
| FirstName: | GLENN | ||||||||
| MiddleName: | JEROME | ||||||||
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| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5959 S SHERWOOD FOREST BLVD | ||||||||
| Address2: | |||||||||
| City: | BATON ROUGE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 708166038 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2255260011 | ||||||||
| FaxNumber: | 2257659196 | ||||||||
| Practice Location | |||||||||
| Address1: | 4950 ESSEN LN STE 503 | ||||||||
| Address2: | |||||||||
| City: | BATON ROUGE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 708093738 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2257651737 | ||||||||
| FaxNumber: | 2257651842 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/25/2011 | ||||||||
| LastUpdateDate: | 12/29/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/29/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LA2200X | 06368 | LA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health |
ID Information
| ID | Type | State | Issuer | Description | 2434045 | 05 | MS | MEDICAID | 2141040 | 05 | LA | MEDICAID | 274780YJA2 | 01 | MEDICARE | OTHER |