Provider Demographics
NPI:1861830101
Name:ALLEN, PHYLLIS A
Entity Type:Individual
Prefix:
First Name:PHYLLIS
Middle Name:A
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 1:4010 N MAIN ST
Mailing Address - Street 2:SUITE 2
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29203-5848
Mailing Address - Country:US
Mailing Address - Phone:803-786-0559
Mailing Address - Fax:803-786-1307
Practice Address - Street 1:4010 N MAIN ST
Practice Address - Street 2:SUITE 2
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29203-5848
Practice Address - Country:US
Practice Address - Phone:803-786-0559
Practice Address - Fax:803-786-1307
Is Sole Proprietor?:No
Enumeration Date:2013-06-10
Last Update Date:2013-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC3133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC3OtherLICENSE NUMBER