Provider Demographics
NPI:1386493526
Name:SMITH, PAMELA DENISE (NURSE PRACTITIONER)
Entity type:Individual
Prefix:MRS
First Name:PAMELA
Middle Name:DENISE
Last Name:SMITH
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4100 N WICKHAM RD UNIT 107A-334
Mailing Address - Street 2:
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32935-2485
Mailing Address - Country:US
Mailing Address - Phone:757-644-9980
Mailing Address - Fax:
Practice Address - Street 1:4100 N WICKHAM RD UNIT 107A-334
Practice Address - Street 2:
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32935-2485
Practice Address - Country:US
Practice Address - Phone:757-644-9980
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-05-17
Last Update Date:2024-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11032874363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology