Provider Demographics
NPI:1972279487
Name:ALLEN, WANITA L
Entity Type:Individual
Prefix:MS
First Name:WANITA
Middle Name:L
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 1:750 E US HIGHWAY 80 STE 200-423
Mailing Address - Street 2:
Mailing Address - City:FORNEY
Mailing Address - State:TX
Mailing Address - Zip Code:75126-8722
Mailing Address - Country:US
Mailing Address - Phone:901-264-3062
Mailing Address - Fax:
Practice Address - Street 1:3829 ANNETTE LN
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38127-4304
Practice Address - Country:US
Practice Address - Phone:901-264-3062
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-17
Last Update Date:2021-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN097502102172A00000X
343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)
No172A00000XOther Service ProvidersDriver