Healthcare Provider Details

I. General information

NPI: 1639621741
Provider Name (Legal Business Name): ELVIA REA ALLEN NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/25/2016
Last Update Date: 08/06/2020
Certification Date: 08/06/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 W. WHITE MOUNTAIN BLVD., SUITE D
LAKESIDE AZ
85929-7014
US

IV. Provider business mailing address

300 W. WHITE MOUNTAIN BLVD., SUITE D
LAKESIDE AZ
85929-7014
US

V. Phone/Fax

Practice location:
  • Phone: 928-368-4547
  • Fax: 928-368-4527
Mailing address:
  • Phone: 928-368-4547
  • Fax: 928-368-4527

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number0089702
License Number StateOK
# 2
Primary TaxonomyY
Taxonomy Code364SF0001X
TaxonomyFamily Health Clinical Nurse Specialist
License NumberAP11398
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: