1134275019 NPI number — MS. PAMELA SUZETTE MILAM CNP

Table of content: MS. PAMELA SUZETTE MILAM CNP (NPI 1134275019)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1134275019 NPI number — MS. PAMELA SUZETTE MILAM CNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MILAM
Provider First Name:
PAMELA
Provider Middle Name:
SUZETTE
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
CNP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
RENFROW (PREVIOUSLY HUNTER)
Provider Other First Name:
SUZETTE
Provider Other Middle Name:
M.
Provider Other Name Prefix Text:
MS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
CNP
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1134275019
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/04/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
9120 NEW HOME RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MARTIN
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
38237
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
731-571-1395
Provider Business Mailing Address Fax Number:
731-587-3460

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
209 WEST STATE LINE RD.
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SOUTH FULTON
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
38257
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
731-479-2112
Provider Business Practice Location Address Fax Number:
731-479-2116
Provider Enumeration Date:
01/25/2007

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: 363L00000X , with the licence number:  0000005426 , 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)

  • Identifier: 4086343 . This is a "BCBS" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
  • Identifier: P00168718 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".




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