Healthcare Provider Details

I. General information

NPI: 1457042996
Provider Name (Legal Business Name): AMY MICHELLE ALLEN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/16/2023
Last Update Date: 05/16/2023
Certification Date: 05/16/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

901 MACARTHUR BLVD
MUNSTER IN
46321-2959
US

IV. Provider business mailing address

2139 RIDGEWOOD ST
HIGHLAND IN
46322-1533
US

V. Phone/Fax

Practice location:
  • Phone: 619-402-7150
  • Fax:
Mailing address:
  • Phone: 619-402-7150
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WC0200X
TaxonomyCritical Care Medicine Registered Nurse
License Number28269557A
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code163WC0200X
TaxonomyCritical Care Medicine Registered Nurse
License Number95121223
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: