Provider Demographics
NPI:1902671308
Name:GASSERT-DEMAN, ALLEGRA
Entity Type:Individual
Prefix:
First Name:ALLEGRA
Middle Name:
Last Name:GASSERT-DEMAN
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 1:6748 ADMIRAL DR
Mailing Address - Street 2:
Mailing Address - City:MIDLAND
Mailing Address - State:GA
Mailing Address - Zip Code:31820-4169
Mailing Address - Country:US
Mailing Address - Phone:360-961-6728
Mailing Address - Fax:
Practice Address - Street 1:6748 ADMIRAL DR
Practice Address - Street 2:
Practice Address - City:MIDLAND
Practice Address - State:GA
Practice Address - Zip Code:31820-4169
Practice Address - Country:US
Practice Address - Phone:360-961-6728
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-11-16
Last Update Date:2023-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA348354174N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174N00000XOther Service ProvidersLactation Consultant, Non-RN