1366687121 NPI number — PAMELA KEELEY CASSELL FNP

Table of content: SAMANTHA GRISSOM (NPI 1144192337)

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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