Basic Information
| Provider Information | |||||||||
| NPI: | 1770068371 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ALLEN | ||||||||
| FirstName: | LOREN | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | FNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9 CAREY RD | ||||||||
| Address2: | |||||||||
| City: | QUEENSBURY | ||||||||
| State: | NY | ||||||||
| PostalCode: | 128047880 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5187610300 | ||||||||
| FaxNumber: | 5188242388 | ||||||||
| Practice Location | |||||||||
| Address1: | 101 ADIRONDACK DR STE 2 | ||||||||
| Address2: | |||||||||
| City: | TICONDEROGA | ||||||||
| State: | NY | ||||||||
| PostalCode: | 128839334 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5185856708 | ||||||||
| FaxNumber: | 5185853260 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/28/2018 | ||||||||
| LastUpdateDate: | 04/04/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/04/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | F343733 | NY | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 05425796 | 05 | NY | MEDICAID |