Provider Demographics
NPI:1437308574
Name:ALLEN, VICKIE JANELL (LMT)
Entity Type:Individual
Prefix:
First Name:VICKIE
Middle Name:JANELL
Last Name:ALLEN
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6910 BRYANT RD
Mailing Address - Street 2:
Mailing Address - City:COCOA
Mailing Address - State:FL
Mailing Address - Zip Code:32927-2983
Mailing Address - Country:US
Mailing Address - Phone:321-749-9781
Mailing Address - Fax:
Practice Address - Street 1:405 FLORIDA AVE
Practice Address - Street 2:2ND FLOOR
Practice Address - City:COCOA
Practice Address - State:FL
Practice Address - Zip Code:32922-7929
Practice Address - Country:US
Practice Address - Phone:321-749-9781
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-09-12
Last Update Date:2008-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA51896174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist