Provider Demographics
NPI:1689477234
Name:ALFONSO, GLEN MAR (EMT, LPN)
Entity type:Individual
Prefix:
First Name:GLEN MAR
Middle Name:
Last Name:ALFONSO
Suffix:
Gender:
Credentials:EMT, LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3624 BELLA LEGATO AVE
Mailing Address - Street 2:
Mailing Address - City:N LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89081-4044
Mailing Address - Country:US
Mailing Address - Phone:725-465-0475
Mailing Address - Fax:
Practice Address - Street 1:250 PILOT RD STE 250
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89119-3514
Practice Address - Country:US
Practice Address - Phone:702-982-3292
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-03-29
Last Update Date:2025-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV886439164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse