Basic Information
| Provider Information | |||||||||
| NPI: | 1679993000 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | NANNEY | ||||||||
| FirstName: | GLENN | ||||||||
| MiddleName: | ALLEN | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 439 WESTWOOD SHOPPING CTR | ||||||||
| Address2: | PMB 4 | ||||||||
| City: | FAYETTEVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 283141532 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 4011 GATEWAY BLVD | ||||||||
| Address2: | |||||||||
| City: | NEWBURGH | ||||||||
| State: | IN | ||||||||
| PostalCode: | 476308947 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8124507246 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/24/2014 | ||||||||
| LastUpdateDate: | 09/03/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/03/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207LP2900X | 2018-02152 | NC | N | Allopathic & Osteopathic Physicians | Anesthesiology | Pain Medicine | 208100000X | 11513A | WY | N | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation | 2081P2900X | 99113777A | IN | Y | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation | Pain Medicine |
No ID Information.