Provider Demographics
NPI:1699775643
Name:GANUS, GLENDA FAYE (FNP)
Entity type:Individual
Prefix:MRS
First Name:GLENDA
Middle Name:FAYE
Last Name:GANUS
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:PO BOX 1237
Mailing Address - Street 2:
Mailing Address - City:CHATOM
Mailing Address - State:AL
Mailing Address - Zip Code:36518-1237
Mailing Address - Country:US
Mailing Address - Phone:251-847-6262
Mailing Address - Fax:251-847-6277
Practice Address - Street 1:14634 SAINT STEPHENS AVE
Practice Address - Street 2:
Practice Address - City:CHATOM
Practice Address - State:AL
Practice Address - Zip Code:36518-6711
Practice Address - Country:US
Practice Address - Phone:251-847-6262
Practice Address - Fax:251-847-6277
Is Sole Proprietor?:No
Enumeration Date:2005-07-29
Last Update Date:2016-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1-031341363L00000X
MSR856711363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL051516689OtherMEDICARE ID
AL529700760Medicaid
AL541003926OtherMEDICAID GROUP
S74184Medicare UPIN