Provider Demographics
NPI:1548342264
Name:ALLEN, LAURA (NP)
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:
Last Name:ALLEN
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:LAURA
Other - Middle Name:E
Other - Last Name:BUTLER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP
Mailing Address - Street 1:150 S HUNTINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:JAMAICA PLAIN
Mailing Address - State:MA
Mailing Address - Zip Code:02130-4893
Mailing Address - Country:US
Mailing Address - Phone:857-364-6772
Mailing Address - Fax:857-364-6589
Practice Address - Street 1:150 S HUNTINGTON AVE
Practice Address - Street 2:
Practice Address - City:JAMAICA PLAIN
Practice Address - State:MA
Practice Address - Zip Code:02130-4893
Practice Address - Country:US
Practice Address - Phone:857-364-6772
Practice Address - Fax:857-364-6589
Is Sole Proprietor?:No
Enumeration Date:2006-10-20
Last Update Date:2021-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA234290363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0702056Medicaid
MA0702056Medicaid
MAUX4267Medicare PIN