1316491673 NPI number — MR. DAVID PETER GLENN PMHNP-BC, RN

Table of content: MR. DAVID PETER GLENN PMHNP-BC, RN (NPI 1316491673)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1316491673 NPI number — MR. DAVID PETER GLENN PMHNP-BC, RN

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GLENN
Provider First Name:
DAVID
Provider Middle Name:
PETER
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
PMHNP-BC, RN
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1316491673
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/10/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4770 INDIANOLA AVE STE 111
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
COLUMBUS
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
43214-1862
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
614-427-3205
Provider Business Mailing Address Fax Number:
727-677-0064

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4770 INDIANOLA AVE
Provider Second Line Business Practice Location Address:
STE 111
Provider Business Practice Location Address City Name:
COLUMBUS
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
43214
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
614-427-3205
Provider Business Practice Location Address Fax Number:
727-677-0064
Provider Enumeration Date:
08/04/2016

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363LP0808X , with the licence number:  APRN.CNP.0029457 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 163W00000X , with the licence number: RN.401849 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 0456482 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".




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