=====================================================
General NPI Number Information
=====================================================
NPI Number | 1205397205
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | TERRY ALLEN NP
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/31/2019
-----------------------------------------------------
Last Update Date | 07/18/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 14555 LEVAN RD STE 311
-----------------------------------------------------
City | LIVONIA
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48154
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 734-655-2692
-----------------------------------------------------
Fax | 734-655-4218
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 24 FRANK LLOYD WRIGHT DRIVE SUITE J2000
-----------------------------------------------------
City | ANN ARBOR
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48105
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 734-747-6766
-----------------------------------------------------
Fax | 734-222-3100
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363L00000X
-----------------------------------------------------
Taxonomy Name | Nurse Practitioner
-----------------------------------------------------
License Number | 4704264054
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------