Provider Demographics
NPI:1871169201
Name:GLASS, DIANE (RN)
Entity type:Individual
Prefix:MS
First Name:DIANE
Middle Name:
Last Name:GLASS
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2867
Mailing Address - Street 2:
Mailing Address - City:MOBILE
Mailing Address - State:AL
Mailing Address - Zip Code:36652-2867
Mailing Address - Country:US
Mailing Address - Phone:251-690-8175
Mailing Address - Fax:251-690-8976
Practice Address - Street 1:251 N BAYOU ST
Practice Address - Street 2:
Practice Address - City:MOBILE
Practice Address - State:AL
Practice Address - Zip Code:36603-5827
Practice Address - Country:US
Practice Address - Phone:251-690-8175
Practice Address - Fax:251-690-8976
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-27
Last Update Date:2021-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1-103516163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse