Provider Demographics
NPI:1104431568
Name:ALLEN, WANDA (DNP, MSN, AGNP-C)
Entity type:Individual
Prefix:
First Name:WANDA
Middle Name:
Last Name:ALLEN
Suffix:
Gender:F
Credentials:DNP, MSN, AGNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 386
Mailing Address - Street 2:
Mailing Address - City:PELHAM
Mailing Address - State:GA
Mailing Address - Zip Code:31779-0386
Mailing Address - Country:US
Mailing Address - Phone:229-328-6555
Mailing Address - Fax:
Practice Address - Street 1:2860 LANDFILL RD
Practice Address - Street 2:
Practice Address - City:PELHAM
Practice Address - State:GA
Practice Address - Zip Code:31779-5960
Practice Address - Country:US
Practice Address - Phone:229-328-6555
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-12
Last Update Date:2020-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN142481363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner