Provider Demographics
NPI:1306998810
Name:ALLEN, SHEREE LAETRELL (PA-C)
Entity type:Individual
Prefix:MISS
First Name:SHEREE
Middle Name:LAETRELL
Last Name:ALLEN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:261 MACK AVE STE 215
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48201-2417
Mailing Address - Country:US
Mailing Address - Phone:313-966-2539
Mailing Address - Fax:313-993-2630
Practice Address - Street 1:261 MACK AVE STE 215
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48201-2417
Practice Address - Country:US
Practice Address - Phone:313-966-2539
Practice Address - Fax:313-993-2630
Is Sole Proprietor?:No
Enumeration Date:2007-01-17
Last Update Date:2018-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601004542363AM0700X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5601004542OtherPA LICENSE #