Provider Demographics
NPI:1720967771
Name:ALLEN, KIM
Entity type:Individual
Prefix:
First Name:KIM
Middle Name:
Last Name:ALLEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:713 GRAND CHAMPION DR STE A1
Mailing Address - Street 2:
Mailing Address - City:ROCKVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20850-5798
Mailing Address - Country:US
Mailing Address - Phone:240-229-8218
Mailing Address - Fax:
Practice Address - Street 1:713 GRAND CHAMPION DR STE A1
Practice Address - Street 2:
Practice Address - City:ROCKVILLE
Practice Address - State:MD
Practice Address - Zip Code:20850-5798
Practice Address - Country:US
Practice Address - Phone:240-229-8218
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-09-02
Last Update Date:2025-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD02274-25-A172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker