1730716648 NPI number — MRS. PAMELA KELLAM GREEN

Table of content: MRS. PAMELA KELLAM GREEN (NPI 1730716648)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1730716648 NPI number — MRS. PAMELA KELLAM GREEN

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GREEN
Provider First Name:
PAMELA
Provider Middle Name:
KELLAM
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
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:
1730716648
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/23/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4575 ST. JOHNS AVENUE
Provider Second Line Business Mailing Address:
SUITE # 4
Provider Business Mailing Address City Name:
JACKSONVILLE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32210
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
904-710-9662
Provider Business Mailing Address Fax Number:
904-586-2473

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6986 JACK HORNER LN
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
JACKSONVILLE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32210-3620
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
904-710-9662
Provider Business Practice Location Address Fax Number:
904-586-2473
Provider Enumeration Date:
03/23/2020

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: 251E00000X , with the licence number:  688784896 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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