Provider Demographics
NPI:1386713287
Name:VANDENBERG, PAMELA KAY (LMP)
Entity type:Individual
Prefix:MS
First Name:PAMELA
Middle Name:KAY
Last Name:VANDENBERG
Suffix:
Gender:F
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6212 75TH ST W
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD
Mailing Address - State:WA
Mailing Address - Zip Code:98499-8368
Mailing Address - Country:US
Mailing Address - Phone:253-222-6568
Mailing Address - Fax:253-272-4760
Practice Address - Street 1:6212 75TH ST W
Practice Address - Street 2:
Practice Address - City:LAKEWOOD
Practice Address - State:WA
Practice Address - Zip Code:98499-8368
Practice Address - Country:US
Practice Address - Phone:253-222-6568
Practice Address - Fax:253-272-4760
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA0014358174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist