Provider Demographics
NPI:1619655453
Name:ALLEN, WINSOME
Entity Type:Individual
Prefix:
First Name:WINSOME
Middle Name:
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 1:3933 W BLOOMFIELD RD
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85029-2976
Mailing Address - Country:US
Mailing Address - Phone:774-994-4580
Mailing Address - Fax:
Practice Address - Street 1:3933 W BLOOMFIELD RD
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85029-2976
Practice Address - Country:US
Practice Address - Phone:774-994-4580
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-07-11
Last Update Date:2023-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZAL12572H310400000X
AZAL12199H310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility