Provider Demographics
NPI:1750119756
Name:ALLEN, MARIA EVITA ISIP
Entity type:Individual
Prefix:
First Name:MARIA EVITA
Middle Name:ISIP
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 1:317 WOODWARD RD
Mailing Address - Street 2:
Mailing Address - City:TRUSSVILLE
Mailing Address - State:AL
Mailing Address - Zip Code:35173-3274
Mailing Address - Country:US
Mailing Address - Phone:205-999-8809
Mailing Address - Fax:
Practice Address - Street 1:317 WOODWARD RD
Practice Address - Street 2:
Practice Address - City:TRUSSVILLE
Practice Address - State:AL
Practice Address - Zip Code:35173-3274
Practice Address - Country:US
Practice Address - Phone:205-999-8809
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-07-23
Last Update Date:2024-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL2727133V00000X
TXDT90576133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered