Provider Demographics
NPI:1316491673
Name:GLENN, DAVID PETER (PMHNP-BC, RN)
Entity type:Individual
Prefix:MR
First Name:DAVID
Middle Name:PETER
Last Name:GLENN
Suffix:
Gender:M
Credentials:PMHNP-BC, RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4770 INDIANOLA AVE STE 111
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43214-1862
Mailing Address - Country:US
Mailing Address - Phone:614-427-3205
Mailing Address - Fax:866-376-9053
Practice Address - Street 1:4770 INDIANOLA AVE STE 111
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43214-1862
Practice Address - Country:US
Practice Address - Phone:614-427-3205
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-04
Last Update Date:2023-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRN.401849163W00000X
OHAPRN.CNP.0029457363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0456482Medicaid