Provider Demographics
NPI:1194132365
Name:GOINES, PAMELA (CNP)
Entity type:Individual
Prefix:
First Name:PAMELA
Middle Name:
Last Name:GOINES
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1509 S CONWELL AVE
Mailing Address - Street 2:
Mailing Address - City:WILLARD
Mailing Address - State:OH
Mailing Address - Zip Code:44890-9448
Mailing Address - Country:US
Mailing Address - Phone:419-964-5140
Mailing Address - Fax:419-964-5722
Practice Address - Street 1:1509 S CONWELL AVE
Practice Address - Street 2:
Practice Address - City:WILLARD
Practice Address - State:OH
Practice Address - Zip Code:44890-9448
Practice Address - Country:US
Practice Address - Phone:419-964-5140
Practice Address - Fax:419-964-5722
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-18
Last Update Date:2024-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHAPRN.CNP.16194363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0108561Medicaid