Basic Information
| Provider Information | |||||||||
| NPI: | 1932220639 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ALLEN | ||||||||
| FirstName: | MOLLYANN | ||||||||
| MiddleName: | G. | ||||||||
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| Credential: | P.A.-C. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8620 N 22ND AVE | ||||||||
| Address2: | 200 | ||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850214251 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6026746506 | ||||||||
| FaxNumber: | 6026746512 | ||||||||
| Practice Location | |||||||||
| Address1: | 18185 N 83RD AVE | ||||||||
| Address2: | BLDG D, STE 107 | ||||||||
| City: | GLENDALE | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 85308 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6235830306 | ||||||||
| FaxNumber: | 6235831349 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/02/2007 | ||||||||
| LastUpdateDate: | 08/20/2008 | ||||||||
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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 | 363A00000X | 2167 | AZ | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 2167 | 01 | AZ | LICENSE | OTHER | 318488 | 05 | AZ | MEDICAID |