Provider Demographics
NPI:1497713408
Name:ALLEN, MYRIAM (OTR)
Entity Type:Individual
Prefix:MRS
First Name:MYRIAM
Middle Name:
Last Name:ALLEN
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:937 E BUENA VISTA AVE
Mailing Address - Street 2:APARTMENT B
Mailing Address - City:GALLUP
Mailing Address - State:NM
Mailing Address - Zip Code:87301-5510
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:505-721-1899
Practice Address - Street 1:1000 E.AZTEC AVE
Practice Address - Street 2:
Practice Address - City:GALLUP
Practice Address - State:NM
Practice Address - Zip Code:87301
Practice Address - Country:US
Practice Address - Phone:505-721-1800
Practice Address - Fax:505-721-1899
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-02
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM1628174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM000F1388Medicaid