Healthcare Provider Details

I. General information

NPI: 1134791411
Provider Name (Legal Business Name): MARK JEFFREY ALLEN FNP-BC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/15/2021
Last Update Date: 09/13/2021
Certification Date: 09/13/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

608 OLD ROUTE 66
SAINT ROBERT MO
65584-3730
US

IV. Provider business mailing address

608 OLD ROUTE 66
SAINT ROBERT MO
65584-3730
US

V. Phone/Fax

Practice location:
  • Phone: 573-336-5100
  • Fax:
Mailing address:
  • Phone: 573-336-5100
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number2021027706
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: