Provider Demographics
NPI:1396490728
Name:ALLEN, MADEA EBONY (LAC)
Entity type:Individual
Prefix:
First Name:MADEA
Middle Name:EBONY
Last Name:ALLEN
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:2401 BRANDERMILL BLVD STE 301
Mailing Address - Street 2:
Mailing Address - City:GAMBRILLS
Mailing Address - State:MD
Mailing Address - Zip Code:21054-1604
Mailing Address - Country:US
Mailing Address - Phone:410-774-0800
Mailing Address - Fax:410-774-0799
Practice Address - Street 1:2401 BRANDERMILL BLVD STE 301
Practice Address - Street 2:
Practice Address - City:GAMBRILLS
Practice Address - State:MD
Practice Address - Zip Code:21054-1604
Practice Address - Country:US
Practice Address - Phone:410-774-0800
Practice Address - Fax:410-774-0799
Is Sole Proprietor?:No
Enumeration Date:2022-02-14
Last Update Date:2022-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDU02893171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist