Basic Information
| Provider Information | |||||||||
| NPI: | 1821182320 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GLENN | ||||||||
| FirstName: | JACQUELINE | ||||||||
| MiddleName: | CHANNELLE | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | RN,MSN | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | CHANNELLE | ||||||||
| OtherFirstName: | JACQUELINE | ||||||||
| OtherMiddleName: | MARQUITO | ||||||||
| OtherNamePrefix: | MS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | RN, MSN | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 249 BILLINGSLEY ROAD | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 28211 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7043364662 | ||||||||
| FaxNumber: | 7043310859 | ||||||||
| Practice Location | |||||||||
| Address1: | 249 BILLINGSLEY ROAD | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 28211 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7043364662 | ||||||||
| FaxNumber: | 7043310859 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/02/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163WC1500X | 050671 | NC | Y | Nursing Service Providers | Registered Nurse | Community Health |
ID Information
| ID | Type | State | Issuer | Description | 01023 | 01 | NC | HEALTH DEPARTMENT | OTHER |