Basic Information
Provider Information | |||||||||
NPI: | 1093003402 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | ALLEN | ||||||||
FirstName: | AIMEE | ||||||||
MiddleName: | E | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | APRN | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | CLARK | ||||||||
OtherFirstName: | AIMEE | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 122108 | ||||||||
Address2: | DEPT 2108 | ||||||||
City: | DALLAS | ||||||||
State: | TX | ||||||||
PostalCode: | 753122108 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3374942919 | ||||||||
FaxNumber: | 3374943069 | ||||||||
Practice Location | |||||||||
Address1: | 1717 OAK PARK BLVD FL 3 | ||||||||
Address2: |   | ||||||||
City: | LAKE CHARLES | ||||||||
State: | LA | ||||||||
PostalCode: | 706018990 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3374758687 | ||||||||
FaxNumber: | 3374758415 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/19/2011 | ||||||||
LastUpdateDate: | 06/06/2014 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | RN111946 AP002592 | LA | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |   |
ID Information
ID | Type | State | Issuer | Description | 267227 | 05 | LA |   | MEDICAID |