Provider Demographics
NPI:1821733593
Name:ALLEN, TISA (LPN)
Entity Type:Individual
Prefix:
First Name:TISA
Middle Name:
Last Name:ALLEN
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2999 PHILADELPHIA PIKE
Mailing Address - Street 2:
Mailing Address - City:CLAYMONT
Mailing Address - State:DE
Mailing Address - Zip Code:19703-2507
Mailing Address - Country:US
Mailing Address - Phone:302-792-0700
Mailing Address - Fax:302-792-0800
Practice Address - Street 1:2999 PHILADELPHIA PIKE
Practice Address - Street 2:
Practice Address - City:CLAYMONT
Practice Address - State:DE
Practice Address - Zip Code:19703-2507
Practice Address - Country:US
Practice Address - Phone:302-792-0700
Practice Address - Fax:302-792-0800
Is Sole Proprietor?:No
Enumeration Date:2022-04-28
Last Update Date:2022-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPN267228164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
DE1114079654Medicaid