Provider Demographics
NPI:1912178781
Name:ALLEN, MARY T (ARNP)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:T
Last Name:ALLEN
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9510 ORMSBY STATION RD STE 530
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40223-4081
Mailing Address - Country:US
Mailing Address - Phone:502-327-1000
Mailing Address - Fax:855-632-8329
Practice Address - Street 1:9510 ORMSBY STATION RD STE 100
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40223-4082
Practice Address - Country:US
Practice Address - Phone:502-327-1000
Practice Address - Fax:855-632-8329
Is Sole Proprietor?:No
Enumeration Date:2008-03-19
Last Update Date:2018-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3005543363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
12166430OtherCAQH
KY7100150970Medicaid