Provider Demographics
NPI:1881252302
Name:ALLEN, MARY GRACE
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:GRACE
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 1:7305 BETHUNE AVE
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78752-2707
Mailing Address - Country:US
Mailing Address - Phone:512-212-0522
Mailing Address - Fax:
Practice Address - Street 1:3508 FAR WEST BLVD STE 130
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78731-3081
Practice Address - Country:US
Practice Address - Phone:512-828-3990
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-30
Last Update Date:2019-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX347258164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse