1932220639 NPI number — MOLLYANN G. ALLEN P.A.-C.

Table of content: MOLLYANN G. ALLEN P.A.-C. (NPI 1932220639)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1932220639 NPI number — MOLLYANN G. ALLEN P.A.-C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ALLEN
Provider First Name:
MOLLYANN
Provider Middle Name:
G.
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
P.A.-C.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1932220639
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/20/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
8620 N 22ND AVE
Provider Second Line Business Mailing Address:
200
Provider Business Mailing Address City Name:
PHOENIX
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85021-4251
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
602-674-6506
Provider Business Mailing Address Fax Number:
602-674-6512

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
18185 N 83RD AVE
Provider Second Line Business Practice Location Address:
BLDG D, STE 107
Provider Business Practice Location Address City Name:
GLENDALE
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85308
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
623-583-0306
Provider Business Practice Location Address Fax Number:
623-583-1349
Provider Enumeration Date:
04/02/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363A00000X , with the licence number:  2167 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 2167 . This is a "LICENSE" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".
  • Identifier: 318488 , issued by the state of ( AZ ) . This identifiers is of the category "MEDICAID".




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