Provider Demographics
NPI:1366235384
Name:DECOLONGON, PAMELA PRAXEDES (AGPCNP-BC)
Entity type:Individual
Prefix:
First Name:PAMELA
Middle Name:PRAXEDES
Last Name:DECOLONGON
Suffix:
Gender:F
Credentials:AGPCNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11020 71ST AVE APT 616
Mailing Address - Street 2:
Mailing Address - City:FOREST HILLS
Mailing Address - State:NY
Mailing Address - Zip Code:11375-4532
Mailing Address - Country:US
Mailing Address - Phone:917-291-0806
Mailing Address - Fax:
Practice Address - Street 1:11020 71ST AVE APT 616
Practice Address - Street 2:
Practice Address - City:FOREST HILLS
Practice Address - State:NY
Practice Address - Zip Code:11375-4532
Practice Address - Country:US
Practice Address - Phone:917-291-0806
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-05-22
Last Update Date:2025-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY312123363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health