Provider Demographics
NPI:1821710690
Name:ALLEN, DESIREE JUANITA
Entity Type:Individual
Prefix:MRS
First Name:DESIREE
Middle Name:JUANITA
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 1:3750 HACKS CROSS RD STE 102-304
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38125-2367
Mailing Address - Country:US
Mailing Address - Phone:617-824-0421
Mailing Address - Fax:
Practice Address - Street 1:496 QUAIL CREST DR
Practice Address - Street 2:
Practice Address - City:COLLIERVILLE
Practice Address - State:TN
Practice Address - Zip Code:38017-1750
Practice Address - Country:US
Practice Address - Phone:617-824-0421
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-09-16
Last Update Date:2023-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
342000000X
TN343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)
No342000000XTransportation ServicesTransportation Network Company
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN220006017Medicaid
TN220006017OtherBUSINESS LICENSE