1366687121 NPI number — PAMELA KEELEY CASSELL FNP

Table of content: PAMELA KEELEY CASSELL FNP (NPI 1366687121)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1366687121 NPI number — PAMELA KEELEY CASSELL FNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CASSELL
Provider First Name:
PAMELA
Provider Middle Name:
KEELEY
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
FNP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1366687121
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/07/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4461 STARKEY RD, SUITE 201
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ROANOKE
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
24018
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
540-345-4946
Provider Business Mailing Address Fax Number:
540-982-7164

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4461 STARKEY RD
Provider Second Line Business Practice Location Address:
STE 201
Provider Business Practice Location Address City Name:
ROANOKE
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
24018-0622
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
540-375-3790
Provider Business Practice Location Address Fax Number:
540-375-8621
Provider Enumeration Date:
12/09/2008

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363LF0000X , with the licence number:  0024167984 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: MC12133 . This is a "MEDICARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 1366687121 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".
  • Identifier: P00679395 . This is a "RR MEDICARE" identifier . This identifiers is of the category "OTHER".




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