Provider Demographics
NPI:1124735915
Name:PUGH, JAMIE RENEA (LPN)
Entity type:Individual
Prefix:
First Name:JAMIE
Middle Name:RENEA
Last Name:PUGH
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:JAMIE
Other - Middle Name:RENEA
Other - Last Name:PHILLIPS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LPN
Mailing Address - Street 1:1750 W BROADWAY
Mailing Address - Street 2:
Mailing Address - City:COUNCIL BLUFFS
Mailing Address - State:IA
Mailing Address - Zip Code:51501-3814
Mailing Address - Country:US
Mailing Address - Phone:712-215-6588
Mailing Address - Fax:
Practice Address - Street 1:1750 W BROADWAY
Practice Address - Street 2:
Practice Address - City:COUNCIL BLUFFS
Practice Address - State:IA
Practice Address - Zip Code:51501-3814
Practice Address - Country:US
Practice Address - Phone:712-215-6588
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-11-01
Last Update Date:2022-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAP46589164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse