Basic Information
| Provider Information | |||||||||
| NPI: | 1841854502 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GLENN-REESE | ||||||||
| FirstName: | LAQUINTA | ||||||||
| MiddleName: | JAMETTE | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 743904 | ||||||||
| Address2: | |||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303743904 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8032967320 | ||||||||
| FaxNumber: | 8032967330 | ||||||||
| Practice Location | |||||||||
| Address1: | 6 RICHLAND MEDICAL PARK DR STE 2100 | ||||||||
| Address2: | |||||||||
| City: | COLUMBIA | ||||||||
| State: | SC | ||||||||
| PostalCode: | 292036864 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8034342762 | ||||||||
| FaxNumber: | 8034342713 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/29/2019 | ||||||||
| LastUpdateDate: | 05/24/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/24/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 21845 | SC | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | NP5950 | 05 | SC | MEDICAID |