Provider Demographics
NPI:1063074904
Name:ALLEN, JAELYNNE MICHELLE (MSN, RN, PNP, CPN)
Entity type:Individual
Prefix:
First Name:JAELYNNE
Middle Name:MICHELLE
Last Name:ALLEN
Suffix:
Gender:F
Credentials:MSN, RN, PNP, CPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:36243 INLAND VALLEY DR
Mailing Address - Street 2:
Mailing Address - City:WILDOMAR
Mailing Address - State:CA
Mailing Address - Zip Code:92595-9549
Mailing Address - Country:US
Mailing Address - Phone:951-813-3760
Mailing Address - Fax:
Practice Address - Street 1:36243 INLAND VALLEY DR
Practice Address - Street 2:
Practice Address - City:WILDOMAR
Practice Address - State:CA
Practice Address - Zip Code:92595-9549
Practice Address - Country:US
Practice Address - Phone:951-813-3760
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-01
Last Update Date:2020-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95011896363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics