Provider Demographics
NPI:1871631192
Name:ALLEN, MARY LEE
Entity Type:Individual
Prefix:MS
First Name:MARY
Middle Name:LEE
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 1:202 W MAIN RD LOT 90
Mailing Address - Street 2:
Mailing Address - City:CONNEAUT
Mailing Address - State:OH
Mailing Address - Zip Code:44030-2050
Mailing Address - Country:US
Mailing Address - Phone:440-223-1612
Mailing Address - Fax:
Practice Address - Street 1:1730 E UNION RD
Practice Address - Street 2:
Practice Address - City:JEFFERSON
Practice Address - State:OH
Practice Address - Zip Code:44047-8657
Practice Address - Country:US
Practice Address - Phone:440-858-2286
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-01
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2496615Medicaid