Healthcare Provider Details

I. General information

NPI: 1366427460
Provider Name (Legal Business Name): RENETTA WALTERS ALLEN NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/12/2005
Last Update Date: 12/04/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11312 JEFFERSON HWY
RIVER RIDGE LA
70123-1709
US

IV. Provider business mailing address

3641 LAKE TIMBERLANE DR
GRETNA LA
70056-8310
US

V. Phone/Fax

Practice location:
  • Phone: 504-463-3002
  • Fax:
Mailing address:
  • Phone: 504-940-7348
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAPO4824
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: