Provider Demographics
NPI:1093003402
Name:ALLEN, AIMEE E (APRN)
Entity Type:Individual
Prefix:
First Name:AIMEE
Middle Name:E
Last Name:ALLEN
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:AIMEE
Other - Middle Name:
Other - Last Name:CLARK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 122108
Mailing Address - Street 2:DEPT 2108
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75312-2108
Mailing Address - Country:US
Mailing Address - Phone:337-494-2919
Mailing Address - Fax:337-494-3069
Practice Address - Street 1:1717 OAK PARK BLVD FL 3
Practice Address - Street 2:
Practice Address - City:LAKE CHARLES
Practice Address - State:LA
Practice Address - Zip Code:70601-8990
Practice Address - Country:US
Practice Address - Phone:337-475-8687
Practice Address - Fax:337-475-8415
Is Sole Proprietor?:No
Enumeration Date:2011-07-19
Last Update Date:2014-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LARN111946 AP002592363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA267227Medicaid