Provider Demographics
NPI:1942589841
Name:ALLEN, LORETTA
Entity Type:Individual
Prefix:
First Name:LORETTA
Middle Name:
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 1:403 WHITESVILLE ST
Mailing Address - Street 2:
Mailing Address - City:LAGRANGE
Mailing Address - State:GA
Mailing Address - Zip Code:30240-5335
Mailing Address - Country:US
Mailing Address - Phone:706-616-5695
Mailing Address - Fax:
Practice Address - Street 1:2100 COMER AVE
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:GA
Practice Address - Zip Code:31904-8725
Practice Address - Country:US
Practice Address - Phone:706-323-0174
Practice Address - Fax:706-256-3264
Is Sole Proprietor?:No
Enumeration Date:2011-08-09
Last Update Date:2011-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA117268163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse