Provider Demographics
NPI:1053044685
Name:ALLEN, MARY GWINDOLYN
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:GWINDOLYN
Last Name:ALLEN
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 1:130 E SAINT MARY AVE
Mailing Address - Street 2:
Mailing Address - City:POTTS CAMP
Mailing Address - State:MS
Mailing Address - Zip Code:38659-4400
Mailing Address - Country:US
Mailing Address - Phone:662-544-1834
Mailing Address - Fax:
Practice Address - Street 1:130 E SAINT MARY AVE
Practice Address - Street 2:
Practice Address - City:POTTS CAMP
Practice Address - State:MS
Practice Address - Zip Code:38659-4400
Practice Address - Country:US
Practice Address - Phone:662-544-1834
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-01
Last Update Date:2022-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant