Provider Demographics
NPI:1932187507
Name:ALLEN, MARK DANIEL (FNP)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:DANIEL
Last Name:ALLEN
Suffix:
Gender:M
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1400 WILLOW LANE
Mailing Address - Street 2:
Mailing Address - City:MANCHESTER
Mailing Address - State:TN
Mailing Address - Zip Code:37355
Mailing Address - Country:US
Mailing Address - Phone:615-500-4048
Mailing Address - Fax:
Practice Address - Street 1:1400 WILLOW LANE
Practice Address - Street 2:
Practice Address - City:MANCHESTER
Practice Address - State:TN
Practice Address - Zip Code:37355
Practice Address - Country:US
Practice Address - Phone:615-500-4048
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-04
Last Update Date:2011-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNAPN 7976363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
4032629OtherBCBS
TN3303612Medicaid
3908565Medicare ID - Type Unspecified
TN3303612Medicaid