Provider Demographics
NPI:1093094906
Name:ALLEN, THERESA D (RN)
Entity Type:Individual
Prefix:
First Name:THERESA
Middle Name:D
Last Name:ALLEN
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:137 HOSPITAL DR. NE
Mailing Address - Street 2:
Mailing Address - City:FORT WALTON BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32548
Mailing Address - Country:US
Mailing Address - Phone:850-833-7400
Mailing Address - Fax:
Practice Address - Street 1:137 HOSPITAL DR. NE
Practice Address - Street 2:
Practice Address - City:FORT WALTON BEACH
Practice Address - State:FL
Practice Address - Zip Code:32548
Practice Address - Country:US
Practice Address - Phone:850-833-7400
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-09
Last Update Date:2011-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRN 9296167163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse