Provider Demographics
NPI:1376080630
Name:ALLEN, MAGIC M (AGACNP-BC)
Entity Type:Individual
Prefix:
First Name:MAGIC
Middle Name:M
Last Name:ALLEN
Suffix:
Gender:F
Credentials:AGACNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:700 E OGDEN AVE STE 202
Mailing Address - Street 2:
Mailing Address - City:WESTMONT
Mailing Address - State:IL
Mailing Address - Zip Code:60559-1398
Mailing Address - Country:US
Mailing Address - Phone:630-789-9785
Mailing Address - Fax:630-789-9798
Practice Address - Street 1:700 E OGDEN AVE STE 202
Practice Address - Street 2:
Practice Address - City:WESTMONT
Practice Address - State:IL
Practice Address - Zip Code:60559-1398
Practice Address - Country:US
Practice Address - Phone:630-789-9785
Practice Address - Fax:630-789-9798
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-25
Last Update Date:2018-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209015500363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care