Provider Demographics
NPI:1073345435
Name:TRAIL, ALLIE
Entity type:Individual
Prefix:
First Name:ALLIE
Middle Name:
Last Name:TRAIL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:39 SOUTHRIDGE CIR
Mailing Address - Street 2:
Mailing Address - City:WYNNE
Mailing Address - State:AR
Mailing Address - Zip Code:72396-8064
Mailing Address - Country:US
Mailing Address - Phone:870-318-6551
Mailing Address - Fax:
Practice Address - Street 1:204 MISSISSIPPI ST S
Practice Address - Street 2:
Practice Address - City:WYNNE
Practice Address - State:AR
Practice Address - Zip Code:72396-3025
Practice Address - Country:US
Practice Address - Phone:870-208-8499
Practice Address - Fax:870-208-8044
Is Sole Proprietor?:Yes
Enumeration Date:2024-08-15
Last Update Date:2024-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator