Provider Demographics
NPI:1912089590
Name:ALLEN, VIVIAN L (APRN-BC)
Entity type:Individual
Prefix:MRS
First Name:VIVIAN
Middle Name:L
Last Name:ALLEN
Suffix:
Gender:F
Credentials:APRN-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2500 STARLING ST STE 501
Mailing Address - Street 2:
Mailing Address - City:BRUNSWICK
Mailing Address - State:GA
Mailing Address - Zip Code:31520-4270
Mailing Address - Country:US
Mailing Address - Phone:912-466-4050
Mailing Address - Fax:912-261-0226
Practice Address - Street 1:2500 STARLING ST STE 501
Practice Address - Street 2:
Practice Address - City:BRUNSWICK
Practice Address - State:GA
Practice Address - Zip Code:31520-4270
Practice Address - Country:US
Practice Address - Phone:912-466-4050
Practice Address - Fax:912-261-0226
Is Sole Proprietor?:No
Enumeration Date:2006-10-20
Last Update Date:2021-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN134633363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAP00444575OtherRAILROAD MEDICARE
GA644542189AMedicaid
GA644542189AMedicaid