Provider Demographics
NPI:1275285751
Name:ALLEN, CHARLES (NURSE PRACTITIONER)
Entity Type:Individual
Prefix:MR
First Name:CHARLES
Middle Name:
Last Name:ALLEN
Suffix:
Gender:M
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 18361
Mailing Address - Street 2:
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64133-8361
Mailing Address - Country:US
Mailing Address - Phone:816-200-2409
Mailing Address - Fax:816-320-0028
Practice Address - Street 1:2321 TROOST AVE STE 101
Practice Address - Street 2:
Practice Address - City:KANSAS CITY
Practice Address - State:MO
Practice Address - Zip Code:64108-2834
Practice Address - Country:US
Practice Address - Phone:816-200-2409
Practice Address - Fax:816-320-0028
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-25
Last Update Date:2023-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO134659711133VN1201X
GA1427617729174V00000X, 261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
No133VN1201XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Obesity and Weight Management
No174V00000XOther Service ProvidersClinical Ethicist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO2301Medicaid
MO417OtherNA