Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 224P00000X | Prosthetist | IL |
NPI | 1063041036 |
---|---|
Provider Name | Tanyale Allen |
First Address | Dolton, IL 60419-2775 |
Second Address | Dolton, IL 60419-2775 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 02/04/2020 |
Last Update Date | 02/04/2020 |