Provider Demographics
NPI:1689329773
Name:ALLEN, STEPHANIE JEAN (PA-C)
Entity Type:Individual
Prefix:MS
First Name:STEPHANIE
Middle Name:JEAN
Last Name:ALLEN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:545 KENNELAND CT APT 106
Mailing Address - Street 2:
Mailing Address - City:CORDOVA
Mailing Address - State:TN
Mailing Address - Zip Code:38018-2212
Mailing Address - Country:US
Mailing Address - Phone:847-847-6595
Mailing Address - Fax:
Practice Address - Street 1:6029 WALNUT GROVE RD STE C002
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38120-2112
Practice Address - Country:US
Practice Address - Phone:901-685-3490
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-02-16
Last Update Date:2022-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN4851363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant