Provider Demographics
NPI:1972112357
Name:GLORIE, MARIE L (NP)
Entity type:Individual
Prefix:
First Name:MARIE
Middle Name:L
Last Name:GLORIE
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4235 THAYER DR
Mailing Address - Street 2:
Mailing Address - City:POWDER SPRINGS
Mailing Address - State:GA
Mailing Address - Zip Code:30127-5651
Mailing Address - Country:US
Mailing Address - Phone:404-985-0242
Mailing Address - Fax:
Practice Address - Street 1:625 W MEMORIAL DR
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:GA
Practice Address - Zip Code:30132-4120
Practice Address - Country:US
Practice Address - Phone:678-903-5103
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-30
Last Update Date:2020-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN217524207QA0505X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult MedicineGroup - Single Specialty