Healthcare Provider Details

I. General information

NPI: 1497713408
Provider Name (Legal Business Name): MYRIAM ALLEN OTR.
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 05/02/2006
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 E.AZTEC AVE
GALLUP NM
87301
US

IV. Provider business mailing address

937 E BUENA VISTA AVE APARTMENT B
GALLUP NM
87301-5510
US

V. Phone/Fax

Practice location:
  • Phone: 505-721-1800
  • Fax: 505-721-1899
Mailing address:
  • Phone:
  • Fax: 505-721-1899

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number1628
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: