Provider Demographics
NPI:1700375094
Name:ALLEN, MYRA BETH (NP)
Entity Type:Individual
Prefix:MS
First Name:MYRA
Middle Name:BETH
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 1:3215 CUSSETA RD
Mailing Address - Street 2:
Mailing Address - City:LANETT
Mailing Address - State:AL
Mailing Address - Zip Code:36863-3882
Mailing Address - Country:US
Mailing Address - Phone:706-773-5627
Mailing Address - Fax:
Practice Address - Street 1:4800 48TH ST
Practice Address - Street 2:
Practice Address - City:VALLEY
Practice Address - State:AL
Practice Address - Zip Code:36854-3666
Practice Address - Country:US
Practice Address - Phone:334-756-9180
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-02
Last Update Date:2018-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1-065136363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care