Provider Demographics
NPI:1386076990
Name:ALLEN, PHILLIP RAY (FNP)
Entity type:Individual
Prefix:
First Name:PHILLIP
Middle Name:RAY
Last Name:ALLEN
Suffix:
Gender:M
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:182 OLD CABIN DR
Mailing Address - Street 2:182 OLD CABIN DRIVE
Mailing Address - City:GLIDE
Mailing Address - State:OR
Mailing Address - Zip Code:97443-9750
Mailing Address - Country:US
Mailing Address - Phone:541-496-0013
Mailing Address - Fax:
Practice Address - Street 1:182 OLD CABIN DR
Practice Address - Street 2:182 OLD CABIN DRIVE
Practice Address - City:GLIDE
Practice Address - State:OR
Practice Address - Zip Code:97443-9750
Practice Address - Country:US
Practice Address - Phone:541-496-0013
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-08-06
Last Update Date:2013-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR200050016363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily