Provider Demographics
NPI:1275371577
Name:LINE, PAMELA NICOLE MARTIN (APRN)
Entity type:Individual
Prefix:
First Name:PAMELA
Middle Name:NICOLE MARTIN
Last Name:LINE
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:104 WATERBURY RD UNIT B
Mailing Address - Street 2:
Mailing Address - City:PROSPECT
Mailing Address - State:CT
Mailing Address - Zip Code:06712-1253
Mailing Address - Country:US
Mailing Address - Phone:860-479-1586
Mailing Address - Fax:949-695-2229
Practice Address - Street 1:104 WATERBURY RD UNIT B
Practice Address - Street 2:
Practice Address - City:PROSPECT
Practice Address - State:CT
Practice Address - Zip Code:06712-1253
Practice Address - Country:US
Practice Address - Phone:860-479-1586
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-07-19
Last Update Date:2024-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT152185163WP0808X
CT13536363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health