Provider Demographics
NPI:1497457121
Name:ALLEN, BRANDON ALEXIE
Entity Type:Individual
Prefix:
First Name:BRANDON
Middle Name:ALEXIE
Last Name:ALLEN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3420 SW CATSKILL DR
Mailing Address - Street 2:
Mailing Address - City:PORT ST LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34953-3545
Mailing Address - Country:US
Mailing Address - Phone:772-342-5043
Mailing Address - Fax:
Practice Address - Street 1:14000 FIVAY RD
Practice Address - Street 2:
Practice Address - City:HUDSON
Practice Address - State:FL
Practice Address - Zip Code:34667-7103
Practice Address - Country:US
Practice Address - Phone:727-861-2929
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-20
Last Update Date:2023-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program