Provider Demographics
NPI:1639621741
Name:ALLEN, ELVIA REA (NP)
Entity Type:Individual
Prefix:MRS
First Name:ELVIA
Middle Name:REA
Last Name:ALLEN
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 W. WHITE MOUNTAIN BLVD., SUITE D
Mailing Address - Street 2:
Mailing Address - City:LAKESIDE
Mailing Address - State:AZ
Mailing Address - Zip Code:85929-7014
Mailing Address - Country:US
Mailing Address - Phone:928-368-4547
Mailing Address - Fax:928-368-4527
Practice Address - Street 1:300 W. WHITE MOUNTAIN BLVD., SUITE D
Practice Address - Street 2:
Practice Address - City:LAKESIDE
Practice Address - State:AZ
Practice Address - Zip Code:85929-7014
Practice Address - Country:US
Practice Address - Phone:928-368-4547
Practice Address - Fax:928-368-4527
Is Sole Proprietor?:No
Enumeration Date:2016-10-25
Last Update Date:2020-08-06
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
OK0089702363LF0000X
AZAP11398364SF0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SF0001XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistFamily Health
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily