Provider Demographics
NPI:1316792245
Name:GLENN, JEANETTE SHANTE (FNP)
Entity type:Individual
Prefix:
First Name:JEANETTE
Middle Name:SHANTE
Last Name:GLENN
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6461 CRESCENT WAY APT 203
Mailing Address - Street 2:
Mailing Address - City:NORFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23513-1410
Mailing Address - Country:US
Mailing Address - Phone:757-761-0497
Mailing Address - Fax:
Practice Address - Street 1:2100 EXECUTIVE DR STE B
Practice Address - Street 2:
Practice Address - City:HAMPTON
Practice Address - State:VA
Practice Address - Zip Code:23666-2402
Practice Address - Country:US
Practice Address - Phone:757-971-7719
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-04-23
Last Update Date:2024-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024190036363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily