Provider Demographics
NPI:1124636501
Name:ALLEN, SHANICE T (MEDICAL ASSISTANT)
Entity type:Individual
Prefix:
First Name:SHANICE
Middle Name:T
Last Name:ALLEN
Suffix:
Gender:F
Credentials:MEDICAL ASSISTANT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4650 N RAINBOW BLVD APT 2200
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89108-5765
Mailing Address - Country:US
Mailing Address - Phone:702-759-6623
Mailing Address - Fax:
Practice Address - Street 1:3450 W CHEYENNE AVE STE 300
Practice Address - Street 2:
Practice Address - City:NORTH LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89032-8223
Practice Address - Country:US
Practice Address - Phone:702-792-0665
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-21
Last Update Date:2020-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty