Provider Demographics
NPI:1306600523
Name:GLENN, VERLYN (PMHNP-BC)
Entity type:Individual
Prefix:
First Name:VERLYN
Middle Name:
Last Name:GLENN
Suffix:
Gender:M
Credentials:PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1711 W WOOD CHIP ST
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-7322
Mailing Address - Country:US
Mailing Address - Phone:509-828-8307
Mailing Address - Fax:
Practice Address - Street 1:1833 S MILLENIUM WAY STE 100
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642-1510
Practice Address - Country:US
Practice Address - Phone:509-828-8307
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-02-08
Last Update Date:2024-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID66417163W00000X
ID2861262363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163W00000XNursing Service ProvidersRegistered Nurse