Provider Demographics
NPI:1528605615
Name:ALLEN, TANA MARIE (NP-C)
Entity Type:Individual
Prefix:MRS
First Name:TANA
Middle Name:MARIE
Last Name:ALLEN
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 LOMA BLANCA LN
Mailing Address - Street 2:
Mailing Address - City:CRESSON
Mailing Address - State:TX
Mailing Address - Zip Code:76035-4612
Mailing Address - Country:US
Mailing Address - Phone:517-316-5639
Mailing Address - Fax:
Practice Address - Street 1:3801 E US HIGHWAY 377 STE 100
Practice Address - Street 2:
Practice Address - City:GRANBURY
Practice Address - State:TX
Practice Address - Zip Code:76049-7620
Practice Address - Country:US
Practice Address - Phone:817-573-1380
Practice Address - Fax:817-573-1381
Is Sole Proprietor?:Yes
Enumeration Date:2019-12-08
Last Update Date:2023-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX943747363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX411116301Medicaid