Provider Demographics
NPI:1215763040
Name:GLANTZ, COURTNEY KATHLEEN LOUISE
Entity type:Individual
Prefix:
First Name:COURTNEY
Middle Name:KATHLEEN LOUISE
Last Name:GLANTZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:902 LAS CRUCES AVE
Mailing Address - Street 2:
Mailing Address - City:RIDGECREST
Mailing Address - State:CA
Mailing Address - Zip Code:93555-3320
Mailing Address - Country:US
Mailing Address - Phone:760-377-7488
Mailing Address - Fax:
Practice Address - Street 1:1081 N CHINA LAKE BLVD
Practice Address - Street 2:
Practice Address - City:RIDGECREST
Practice Address - State:CA
Practice Address - Zip Code:93555-3130
Practice Address - Country:US
Practice Address - Phone:760-446-3551
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-09-09
Last Update Date:2024-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95032077363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care