Basic Information
| Provider Information | |||||||||
| NPI: | 1639371958 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ALLEN | ||||||||
| FirstName: | MARY | ||||||||
| MiddleName: | LOUISE | ||||||||
| NamePrefix: | MISS | ||||||||
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| Credential: | CNM | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2979 PGA BLVD | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | PALM BEACH GARDENS | ||||||||
| State: | FL | ||||||||
| PostalCode: | 334102911 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5612757604 | ||||||||
| FaxNumber: | 5618025385 | ||||||||
| Practice Location | |||||||||
| Address1: | 927 45TH ST | ||||||||
| Address2: | SUITE 303 | ||||||||
| City: | WEST PALM BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 334072450 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5618815454 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/31/2007 | ||||||||
| LastUpdateDate: | 01/20/2014 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367A00000X | 9244332 | FL | Y | Physician Assistants & Advanced Practice Nursing Providers | Advanced Practice Midwife |
ID Information
| ID | Type | State | Issuer | Description | 308010200 | 05 | FL | MEDICAID |