Provider Demographics
NPI:1023218674
Name:MASSEY, PAMELA S (CFNP)
Entity Type:Individual
Prefix:MRS
First Name:PAMELA
Middle Name:S
Last Name:MASSEY
Suffix:
Gender:F
Credentials:CFNP
Other - Prefix:MRS
Other - First Name:PAMELA
Other - Middle Name:S
Other - Last Name:LUKE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CFNP
Mailing Address - Street 1:305 WILLOW RUN
Mailing Address - Street 2:
Mailing Address - City:PEARL
Mailing Address - State:MS
Mailing Address - Zip Code:39208-8075
Mailing Address - Country:US
Mailing Address - Phone:601-750-9742
Mailing Address - Fax:601-825-7893
Practice Address - Street 1:1500 E WOODROW WILSON AVE
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39216-5116
Practice Address - Country:US
Practice Address - Phone:601-364-1356
Practice Address - Fax:601-364-1357
Is Sole Proprietor?:No
Enumeration Date:2007-07-23
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR853758363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS09958067Medicaid
MS512I500409Medicare PIN