Basic Information
| Provider Information | |||||||||
| NPI: | 1952732869 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ALLEN | ||||||||
| FirstName: | BRONWYN | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | CPNP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | BACKSTROM | ||||||||
| OtherFirstName: | BRONWYN | ||||||||
| OtherMiddleName: | |||||||||
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| OtherCredential: | NP | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 2330 JENA ST | ||||||||
| Address2: | |||||||||
| City: | NEW ORLEANS | ||||||||
| State: | LA | ||||||||
| PostalCode: | 701155906 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5047227687 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1315 JEFFERSON HWY | ||||||||
| Address2: | |||||||||
| City: | NEW ORLEANS | ||||||||
| State: | LA | ||||||||
| PostalCode: | 701212406 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5048423900 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/02/2013 | ||||||||
| LastUpdateDate: | 11/05/2018 | ||||||||
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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 | 364SP0200X | 382418 | NY | N | Physician Assistants & Advanced Practice Nursing Providers | Clinical Nurse Specialist | Pediatrics | 363LP0200X | AP08498 | LA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 07455236 | 05 | MS | MEDICAID | 2401700 | 05 | LA | MEDICAID |