Provider Demographics
NPI:1750774311
Name:DISNEY, PAMELA LYNNE
Entity type:Individual
Prefix:
First Name:PAMELA
Middle Name:LYNNE
Last Name:DISNEY
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 1:217 NEWMAN ST
Mailing Address - Street 2:
Mailing Address - City:ROSCOMMON
Mailing Address - State:MI
Mailing Address - Zip Code:48653-7603
Mailing Address - Country:US
Mailing Address - Phone:989-390-6580
Mailing Address - Fax:
Practice Address - Street 1:217 NEWMAN ST
Practice Address - Street 2:
Practice Address - City:ROSCOMMON
Practice Address - State:MI
Practice Address - Zip Code:48653-7603
Practice Address - Country:US
Practice Address - Phone:989-390-6580
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-03-06
Last Update Date:2015-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4703109354164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse