Provider Demographics
NPI:1841854502
Name:GLENN-REESE, LAQUINTA JAMETTE
Entity type:Individual
Prefix:MRS
First Name:LAQUINTA
Middle Name:JAMETTE
Last Name:GLENN-REESE
Suffix:
Gender:F
Credentials:
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 6069
Mailing Address - Street 2:
Mailing Address - City:WEST COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29171-6069
Mailing Address - Country:US
Mailing Address - Phone:803-791-2491
Mailing Address - Fax:
Practice Address - Street 1:222 E MEDICAL LN STE 400
Practice Address - Street 2:
Practice Address - City:WEST COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29169-4848
Practice Address - Country:US
Practice Address - Phone:803-794-7511
Practice Address - Fax:803-794-7751
Is Sole Proprietor?:No
Enumeration Date:2019-04-29
Last Update Date:2025-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC21845363LA2200X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCNP5950Medicaid