1902145725 NPI number — PAMELA ROUSH LPN

Table of content: PAMELA ROUSH LPN (NPI 1902145725)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1902145725 NPI number — PAMELA ROUSH LPN

Organization/Personal Information

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

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
LEONARD
Provider Other First Name:
PAMELA
Provider Other Middle Name:
DARLENE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1902145725
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/28/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
515 CLANTON RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CHARLOTTE
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28217-1309
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
704-332-9001
Provider Business Mailing Address Fax Number:
704-714-1182

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
150 DEN-MAC DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BOONE
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28607-6543
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
828-263-8171
Provider Business Practice Location Address Fax Number:
828-263-0995
Provider Enumeration Date:
02/14/2013

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: 164W00000X , with the licence number:  59457 , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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