Provider Demographics
NPI:1679171144
Name:ALLEN, DERRICK L
Entity type:Individual
Prefix:
First Name:DERRICK
Middle Name:L
Last Name:ALLEN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:DERRICK
Other - Middle Name:L
Other - Last Name:ALLEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:355 BLUEFIELD AVE
Mailing Address - Street 2:
Mailing Address - City:BLUEFIELD
Mailing Address - State:WV
Mailing Address - Zip Code:24701-2883
Mailing Address - Country:US
Mailing Address - Phone:304-425-7111
Mailing Address - Fax:304-425-1138
Practice Address - Street 1:600 TRENT STREET
Practice Address - Street 2:
Practice Address - City:PRINCETON
Practice Address - State:WV
Practice Address - Zip Code:24740
Practice Address - Country:US
Practice Address - Phone:304-425-7111
Practice Address - Fax:304-425-1138
Is Sole Proprietor?:No
Enumeration Date:2020-10-15
Last Update Date:2021-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV15687960273747P1801X, 376J00000X
3747P1801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant
No376J00000XNursing Service Related ProvidersHomemaker
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV55-6025355Medicaid