Provider Demographics
NPI:1912293838
Name:GLENN, NICOLE CHRISTINE (MD)
Entity type:Individual
Prefix:
First Name:NICOLE CHRISTINE
Middle Name:
Last Name:GLENN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:NICOLE CHRISTINE
Other - Middle Name:
Other - Last Name:DEINHAMMER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4050 DUBLIN BLVD FL 2
Mailing Address - Street 2:
Mailing Address - City:DUBLIN
Mailing Address - State:CA
Mailing Address - Zip Code:94568-3112
Mailing Address - Country:US
Mailing Address - Phone:925-875-6100
Mailing Address - Fax:
Practice Address - Street 1:4050 DUBLIN BLVD
Practice Address - Street 2:
Practice Address - City:DUBLIN
Practice Address - State:CA
Practice Address - Zip Code:94568-3112
Practice Address - Country:US
Practice Address - Phone:925-875-6100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-06-20
Last Update Date:2024-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA122582208000000X
CA390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program