Provider Demographics
NPI:1538392808
Name:ROSS, PAMELA WALLIS
Entity type:Individual
Prefix:
First Name:PAMELA
Middle Name:WALLIS
Last Name:ROSS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:PAMELA
Other - Middle Name:
Other - Last Name:ROSS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PT
Mailing Address - Street 1:1313 JUMANA LOOP
Mailing Address - Street 2:
Mailing Address - City:APOLLO BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33572-2914
Mailing Address - Country:US
Mailing Address - Phone:813-641-0414
Mailing Address - Fax:
Practice Address - Street 1:6418 US HIGHWAY 41 N
Practice Address - Street 2:
Practice Address - City:APOLLO BEACH
Practice Address - State:FL
Practice Address - Zip Code:33572-1803
Practice Address - Country:US
Practice Address - Phone:813-649-0339
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-09-02
Last Update Date:2009-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL20101225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist