Provider Demographics
NPI:1124345897
Name:KELLY, PAMELA STAUFFER
Entity type:Individual
Prefix:
First Name:PAMELA
Middle Name:STAUFFER
Last Name:KELLY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:569 58TH ST
Mailing Address - Street 2:APARTMENT 1R
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11220-3847
Mailing Address - Country:US
Mailing Address - Phone:509-668-3978
Mailing Address - Fax:
Practice Address - Street 1:569 58TH ST
Practice Address - Street 2:APARTMENT 1R
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11220-3847
Practice Address - Country:US
Practice Address - Phone:509-668-3978
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-04-21
Last Update Date:2010-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY626845-1163W00000X
WA00103209163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse