Healthcare Provider Details

I. General information

NPI: 1538708912
Provider Name (Legal Business Name): DEANDRE DAVID ALLEN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/02/2020
Last Update Date: 01/02/2020
Certification Date: 01/02/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5274 FINKAS LN
FAIRFIELD CA
94533-1556
US

IV. Provider business mailing address

5274 FINKAS LN
FAIRFIELD CA
94533-1556
US

V. Phone/Fax

Practice location:
  • Phone: 707-419-9689
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174H00000X
TaxonomyHealth Educator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: