Provider Demographics
NPI:1841356441
Name:FERNANDES, GLENN R (APRN, BC)
Entity type:Individual
Prefix:MR
First Name:GLENN
Middle Name:R
Last Name:FERNANDES
Suffix:
Gender:M
Credentials:APRN, BC
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Mailing Address - Street 1:1005 MAR WALT DR
Mailing Address - Street 2:
Mailing Address - City:FORT WALTON BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32547-6707
Mailing Address - Country:US
Mailing Address - Phone:850-863-8100
Mailing Address - Fax:850-863-4152
Practice Address - Street 1:1032 MAR WALT DR UNIT 210
Practice Address - Street 2:
Practice Address - City:FORT WALTON BEACH
Practice Address - State:FL
Practice Address - Zip Code:32547-6661
Practice Address - Country:US
Practice Address - Phone:508-638-2608
Practice Address - Fax:850-862-6098
Is Sole Proprietor?:No
Enumeration Date:2006-12-28
Last Update Date:2022-07-18
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
GARN126877363LF0000X
FLAPRN11017375363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAVAD000Medicare UPIN