Provider Demographics
NPI:1710071758
Name:ALLEN, MARY K
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:K
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 1:4700 TAMA ST SE
Mailing Address - Street 2:STE 700
Mailing Address - City:CEDAR RAPIDS
Mailing Address - State:IA
Mailing Address - Zip Code:52403-4556
Mailing Address - Country:US
Mailing Address - Phone:319-447-0700
Mailing Address - Fax:319-447-0808
Practice Address - Street 1:2166 BLAIRS FERRY RD
Practice Address - Street 2:
Practice Address - City:HIAWATHA
Practice Address - State:IA
Practice Address - Zip Code:52233-7902
Practice Address - Country:US
Practice Address - Phone:319-395-6000
Practice Address - Fax:319-395-6015
Is Sole Proprietor?:No
Enumeration Date:2006-10-03
Last Update Date:2009-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA03196225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0665430Medicaid
IAIB1212009Medicare PIN
IAIB1213Medicare PIN
IA0665430Medicaid
IAIB1212Medicare PIN