Provider Demographics
NPI:1134773237
Name:ALLEN, DOLETA MICSHAYE
Entity type:Individual
Prefix:
First Name:DOLETA
Middle Name:MICSHAYE
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 1:4018 BLACKBIRD CT
Mailing Address - Street 2:
Mailing Address - City:WALDORF
Mailing Address - State:MD
Mailing Address - Zip Code:20603-4642
Mailing Address - Country:US
Mailing Address - Phone:301-638-3194
Mailing Address - Fax:
Practice Address - Street 1:4018 BLACKBIRD CT
Practice Address - Street 2:
Practice Address - City:WALDORF
Practice Address - State:MD
Practice Address - Zip Code:20603-4642
Practice Address - Country:US
Practice Address - Phone:301-638-3194
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-26
Last Update Date:2019-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD08AL0143-A310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility