Provider Demographics
NPI:1578237996
Name:ALLEN, OMOTAYO GRACE (NP)
Entity type:Individual
Prefix:
First Name:OMOTAYO
Middle Name:GRACE
Last Name:ALLEN
Suffix:
Gender:F
Credentials:NP
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Other - Credentials:
Mailing Address - Street 1:440 N BARRANCA AVE # 1801
Mailing Address - Street 2:
Mailing Address - City:COVINA
Mailing Address - State:CA
Mailing Address - Zip Code:91723-1722
Mailing Address - Country:US
Mailing Address - Phone:800-924-7811
Mailing Address - Fax:877-349-1868
Practice Address - Street 1:7008 SALEM AVE # 117
Practice Address - Street 2:
Practice Address - City:LUBBOCK
Practice Address - State:TX
Practice Address - Zip Code:79424-2226
Practice Address - Country:US
Practice Address - Phone:800-924-7811
Practice Address - Fax:877-349-1868
Is Sole Proprietor?:No
Enumeration Date:2021-08-09
Last Update Date:2025-02-13
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
OH0037714363LF0000X
TX1114006363LF0000X
MO2024045186363LF0000X
MI4704352831363LF0000X
PASP031595363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily