1083797518 NPI number — MRS. PAMELA SUE NETHERY APRN, BC, FNP

Table of content: MRS. PAMELA SUE NETHERY APRN, BC, FNP (NPI 1083797518)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1083797518 NPI number — MRS. PAMELA SUE NETHERY APRN, BC, FNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
NETHERY
Provider First Name:
PAMELA
Provider Middle Name:
SUE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
APRN, BC, FNP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
LAURSEN
Provider Other First Name:
PAMELA
Provider Other Middle Name:
SUE
Provider Other Name Prefix Text:
MISS
Provider Other Name Suffix Text:
Provider Other Credential Text:
BSN
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1083797518
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
15312 BROOKLODGE RD.
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HICKORY CORNERS
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
49060-9740
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
269-671-4850
Provider Business Mailing Address Fax Number:
269-671-4850

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
327 CAPITAL AVE NE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BATTLE CREEK
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
49017-3924
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
269-969-6040
Provider Business Practice Location Address Fax Number:
269-969-6041
Provider Enumeration Date:
10/20/2006

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:  4704136276 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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