Provider Demographics
NPI:1285917633
Name:WILSON, PAMALA ANN (LM, CPM)
Entity type:Individual
Prefix:MRS
First Name:PAMALA
Middle Name:ANN
Last Name:WILSON
Suffix:
Gender:F
Credentials:LM, CPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14717 BRIDLE TRACE LN
Mailing Address - Street 2:
Mailing Address - City:PINEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28134-9148
Mailing Address - Country:US
Mailing Address - Phone:518-368-3605
Mailing Address - Fax:
Practice Address - Street 1:14717 BRIDLE TRACE LN
Practice Address - Street 2:
Practice Address - City:PINEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28134-9148
Practice Address - Country:US
Practice Address - Phone:518-368-3605
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-22
Last Update Date:2011-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCLMW-0051176B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes176B00000XOther Service ProvidersMidwife