Provider Demographics
NPI:1962929802
Name:ALLEN, AUDRA MICHELLE
Entity type:Individual
Prefix:
First Name:AUDRA
Middle Name:MICHELLE
Last Name:ALLEN
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 1:102 MARTHAS LOOP
Mailing Address - Street 2:
Mailing Address - City:CUSSETA
Mailing Address - State:GA
Mailing Address - Zip Code:31805-3820
Mailing Address - Country:US
Mailing Address - Phone:762-233-3055
Mailing Address - Fax:
Practice Address - Street 1:102 MARTHAS LOOP
Practice Address - Street 2:
Practice Address - City:CUSSETA
Practice Address - State:GA
Practice Address - Zip Code:31805-3820
Practice Address - Country:US
Practice Address - Phone:762-233-3055
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-22
Last Update Date:2017-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA2200596163WH0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WH0200XNursing Service ProvidersRegistered NurseHome Health