Provider Demographics
NPI:1568695179
Name:ALLEN, ANGELA MICHELE
Entity Type:Individual
Prefix:
First Name:ANGELA
Middle Name:MICHELE
Last Name:ALLEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3956 MOUNT ELLIOTT STREET
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48207-1841
Mailing Address - Country:US
Mailing Address - Phone:313-925-4540
Mailing Address - Fax:313-925-4604
Practice Address - Street 1:3956 MOUNT ELLIOTT ST
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48207-1841
Practice Address - Country:US
Practice Address - Phone:313-925-4540
Practice Address - Fax:313-925-4604
Is Sole Proprietor?:No
Enumeration Date:2009-08-29
Last Update Date:2015-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704198201363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily