Healthcare Provider Details

I. General information

NPI: 1023389798
Provider Name (Legal Business Name): ROBERT D. ALLEN RN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/26/2012
Last Update Date: 01/26/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

516 NIZHONI BLZD
GALLUP NM
87301
US

IV. Provider business mailing address

516 NIZHONI BLZD
GALLUP NM
87301-1337
US

V. Phone/Fax

Practice location:
  • Phone: 505-722-1000
  • Fax: 505-722-1310
Mailing address:
  • Phone: 505-722-1000
  • Fax: 505-722-1310

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number103515
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: