Provider Demographics
NPI:1104493055
Name:DAVIS GOODACRE, PAMELA DELORIS (LVN)
Entity type:Individual
Prefix:
First Name:PAMELA
Middle Name:DELORIS
Last Name:DAVIS GOODACRE
Suffix:
Gender:F
Credentials:LVN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:331 E TAMARACK AVE APT 7
Mailing Address - Street 2:
Mailing Address - City:INGLEWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:90301-2759
Mailing Address - Country:US
Mailing Address - Phone:661-992-2956
Mailing Address - Fax:
Practice Address - Street 1:4450 W CENTURY BLVD
Practice Address - Street 2:
Practice Address - City:INGLEWOOD
Practice Address - State:CA
Practice Address - Zip Code:90304-1504
Practice Address - Country:US
Practice Address - Phone:310-671-0555
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-09
Last Update Date:2021-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA151365164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes164X00000XNursing Service ProvidersLicensed Vocational NurseGroup - Single Specialty