Provider Demographics
NPI:1790872158
Name:ALLEN, RENAI (NP)
Entity Type:Individual
Prefix:
First Name:RENAI
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 1:3630 WINDLAKE DR
Mailing Address - Street 2:
Mailing Address - City:SNELLVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30039-5241
Mailing Address - Country:US
Mailing Address - Phone:617-699-5013
Mailing Address - Fax:
Practice Address - Street 1:4398 ATLANTA HWY
Practice Address - Street 2:
Practice Address - City:LOGANVILLE
Practice Address - State:GA
Practice Address - Zip Code:30052-7314
Practice Address - Country:US
Practice Address - Phone:617-699-5013
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-06
Last Update Date:2020-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN222518363LF0000X
MA260064363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA260064OtherMASS BORM LICENSE
FLAPRN11006495OtherFL BORN
NH063977-23OtherNH BORN
GA222518OtherGA BORN LICENSE