Basic Information
| Provider Information | |||||||||
| NPI: | 1114224623 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ALLEN | ||||||||
| FirstName: | REBECCA | ||||||||
| MiddleName: | JOAN | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | CRNA | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | MAIDEN | ||||||||
| OtherFirstName: | REBECCA | ||||||||
| OtherMiddleName: | JOAN | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | CRNA | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 840853 | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752840853 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9722331999 | ||||||||
| FaxNumber: | 9722333666 | ||||||||
| Practice Location | |||||||||
| Address1: | 5605 N MACARTHUR BLVD | ||||||||
| Address2: | STE. 220 | ||||||||
| City: | IRVING | ||||||||
| State: | TX | ||||||||
| PostalCode: | 75038 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9727140007 | ||||||||
| FaxNumber: | 9725734046 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/17/2011 | ||||||||
| LastUpdateDate: | 05/29/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | 24169180 | VA | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered | 367500000X | 727430 | TX | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | 300410302 | 05 | TX | MEDICAID | 8203UD | 01 | TX | BCBS | OTHER |