=====================================================
General NPI Number Information
=====================================================
NPI Number | 1043235153
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | NIKKI ALLEN MD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/12/2006
-----------------------------------------------------
Last Update Date | 09/21/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4580 S NICHOLSON AVE
-----------------------------------------------------
City | CUDAHY
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53110-1360
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 414-326-4800
-----------------------------------------------------
Fax | 855-270-4751
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4580 S NICHOLSON AVE
-----------------------------------------------------
City | CUDAHY
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53110-1360
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 414-326-4800
-----------------------------------------------------
Fax | 855-720-4751
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | 43605-020
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------