Provider Demographics
NPI:1275097362
Name:LOVE-GLENN, TAHIRA KANEKA (NURSE PRACTITIONER)
Entity type:Individual
Prefix:
First Name:TAHIRA
Middle Name:KANEKA
Last Name:LOVE-GLENN
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3989 CUMBERLAND TRL SE
Mailing Address - Street 2:
Mailing Address - City:CONYERS
Mailing Address - State:GA
Mailing Address - Zip Code:30094-3889
Mailing Address - Country:US
Mailing Address - Phone:770-286-6992
Mailing Address - Fax:
Practice Address - Street 1:3565 GEORGIA HIGHWAY 20 SE
Practice Address - Street 2:
Practice Address - City:CONYERS
Practice Address - State:GA
Practice Address - Zip Code:30013-2800
Practice Address - Country:US
Practice Address - Phone:404-430-1757
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-23
Last Update Date:2024-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN239826363LG0600X, 163W00000X, 363LP2300X, 363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
No163W00000XNursing Service ProvidersRegistered Nurse
No363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care