Provider Demographics
NPI:1689318578
Name:ALLEN, AMANDA (NP)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:
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 1:550 BOURROUS DR
Mailing Address - Street 2:
Mailing Address - City:DIBOLL
Mailing Address - State:TX
Mailing Address - Zip Code:75941-4724
Mailing Address - Country:US
Mailing Address - Phone:936-366-2348
Mailing Address - Fax:
Practice Address - Street 1:111 E SHEPHERD AVE
Practice Address - Street 2:
Practice Address - City:LUFKIN
Practice Address - State:TX
Practice Address - Zip Code:75901-0315
Practice Address - Country:US
Practice Address - Phone:936-366-2348
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-04-26
Last Update Date:2022-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1075604363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology