Provider Demographics
NPI:1003801028
Name:DOUGLAS, PAMELA KAVANAUGH (MSN,APRN,BC)
Entity Type:Individual
Prefix:MS
First Name:PAMELA
Middle Name:KAVANAUGH
Last Name:DOUGLAS
Suffix:
Gender:F
Credentials:MSN,APRN,BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6722 PATTERSON AVE
Mailing Address - Street 2:SUITE B
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23226-3419
Mailing Address - Country:US
Mailing Address - Phone:804-282-4000
Mailing Address - Fax:804-282-7799
Practice Address - Street 1:6722 PATTERSON AVE
Practice Address - Street 2:SUITE B
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23226-3419
Practice Address - Country:US
Practice Address - Phone:804-282-4000
Practice Address - Fax:804-282-7799
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0015000655101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
00W274P01Medicare ID - Type Unspecified
P26528Medicare UPIN