1033574967 NPI number — MS. PAMELA J NICHOLSON RD, LDN

Table of content: MS. PAMELA J NICHOLSON RD, LDN (NPI 1033574967)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1033574967 NPI number — MS. PAMELA J NICHOLSON RD, LDN

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
NICHOLSON
Provider First Name:
PAMELA
Provider Middle Name:
J
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
RD, LDN
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:
1033574967
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/18/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1 ELMBANK DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BELLEVILLE
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
62226-4924
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
618-401-5361
Provider Business Mailing Address Fax Number:
618-257-6616

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4500 MEMORIAL DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BELLEVILLE
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
62226-5360
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
618-257-4377
Provider Business Practice Location Address Fax Number:
618-257-6616
Provider Enumeration Date:
12/18/2015

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: 133V00000X , with the licence number:  164.000914 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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