Healthcare Provider Details

I. General information

NPI: 1063924405
Provider Name (Legal Business Name): ANGELA ALLEN-BLAINE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/25/2017
Last Update Date: 05/30/2023
Certification Date: 05/30/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1901 E FRANKLIN ST STE 108
RICHMOND VA
23223-6966
US

IV. Provider business mailing address

PO BOX 159
LAWRENCEVILLE VA
23868-0159
US

V. Phone/Fax

Practice location:
  • Phone: 617-379-0496
  • Fax: 617-379-0434
Mailing address:
  • Phone: 434-917-0970
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number0001204274
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number0024175587
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: