Provider Demographics
NPI:1609692797
Name:GLOSE, MARTHA E (NP)
Entity type:Individual
Prefix:
First Name:MARTHA
Middle Name:E
Last Name:GLOSE
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:105 LAKEVIEW DR
Mailing Address - Street 2:
Mailing Address - City:THOMASVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:31792-5335
Mailing Address - Country:US
Mailing Address - Phone:229-221-9834
Mailing Address - Fax:
Practice Address - Street 1:105 LAKEVIEW DR
Practice Address - Street 2:
Practice Address - City:THOMASVILLE
Practice Address - State:GA
Practice Address - Zip Code:31792-5335
Practice Address - Country:US
Practice Address - Phone:229-221-9834
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-11-23
Last Update Date:2024-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN165725363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily