Provider Demographics
NPI:1992241962
Name:ALLEN, KEYEARA MONA (LPC)
Entity type:Individual
Prefix:
First Name:KEYEARA
Middle Name:MONA
Last Name:ALLEN
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4271 S LEE ST
Mailing Address - Street 2:101 & 102
Mailing Address - City:BUFORD
Mailing Address - State:GA
Mailing Address - Zip Code:30518-3710
Mailing Address - Country:US
Mailing Address - Phone:678-765-8160
Mailing Address - Fax:
Practice Address - Street 1:4271 S LEE ST
Practice Address - Street 2:101 & 102
Practice Address - City:BUFORD
Practice Address - State:GA
Practice Address - Zip Code:30518-3710
Practice Address - Country:US
Practice Address - Phone:678-765-8160
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-13
Last Update Date:2017-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPN093043164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse