Provider Demographics
NPI:1104932896
Name:LOUDERBACK, PAMELA D (ARNP)
Entity type:Individual
Prefix:
First Name:PAMELA
Middle Name:D
Last Name:LOUDERBACK
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5220 BELFORT RD
Mailing Address - Street 2:SUITE 130
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32256-6017
Mailing Address - Country:US
Mailing Address - Phone:904-446-3701
Mailing Address - Fax:888-507-9833
Practice Address - Street 1:700 6TH STREET SOUTH
Practice Address - Street 2:
Practice Address - City:ST. PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33701-4814
Practice Address - Country:US
Practice Address - Phone:904-446-3701
Practice Address - Fax:888-507-9833
Is Sole Proprietor?:No
Enumeration Date:2006-08-22
Last Update Date:2022-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP10958122083P0011X, 163WW0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WW0000XNursing Service ProvidersRegistered NurseWound Care
No2083P0011XAllopathic & Osteopathic PhysiciansPreventive MedicineUndersea and Hyperbaric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL304014300Medicaid
7373704OtherAETNA
P00226381OtherRAILROAD MEDICARE
P00226381OtherRAILROAD MEDICARE
FLU2957ZMedicare ID - Type Unspecified