Provider Demographics
NPI:1033244694
Name:STAFFORD, PAMELA S
Entity Type:Individual
Prefix:
First Name:PAMELA
Middle Name:S
Last Name:STAFFORD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:PAMELA
Other - Middle Name:S
Other - Last Name:GUILTNER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:518 N HAMPTON AVE
Mailing Address - Street 2:
Mailing Address - City:REPUBLIC
Mailing Address - State:MO
Mailing Address - Zip Code:65738-1323
Mailing Address - Country:US
Mailing Address - Phone:417-732-3605
Mailing Address - Fax:417-732-3609
Practice Address - Street 1:518 N HAMPTON AVE
Practice Address - Street 2:
Practice Address - City:REPUBLIC
Practice Address - State:MO
Practice Address - Zip Code:65738-1323
Practice Address - Country:US
Practice Address - Phone:417-732-3605
Practice Address - Fax:417-732-3609
Is Sole Proprietor?:No
Enumeration Date:2007-02-23
Last Update Date:2010-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO01975235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO464450402Medicaid