Provider Demographics
NPI:1447291596
Name:GLICK, MARY ANN (NP)
Entity type:Individual
Prefix:
First Name:MARY ANN
Middle Name:
Last Name:GLICK
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:306 HEMPSTEAD AVE
Mailing Address - Street 2:
Mailing Address - City:MALVERNE
Mailing Address - State:NY
Mailing Address - Zip Code:11565-1201
Mailing Address - Country:US
Mailing Address - Phone:516-678-0076
Mailing Address - Fax:516-763-0981
Practice Address - Street 1:306 HEMPSTEAD AVE
Practice Address - Street 2:
Practice Address - City:MALVERNE
Practice Address - State:NY
Practice Address - Zip Code:11565-1201
Practice Address - Country:US
Practice Address - Phone:516-678-0076
Practice Address - Fax:516-763-0981
Is Sole Proprietor?:No
Enumeration Date:2006-06-09
Last Update Date:2016-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY212311-1363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner