Provider Demographics
NPI:1043279466
Name:BUCKALLEW, PAMELA SUE (ARNP)
Entity Type:Individual
Prefix:
First Name:PAMELA
Middle Name:SUE
Last Name:BUCKALLEW
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:PAMELA
Other - Middle Name:SUE
Other - Last Name:SIMS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4311 SALISBURY ROAD
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32216
Mailing Address - Country:US
Mailing Address - Phone:904-332-4316
Mailing Address - Fax:904-332-4339
Practice Address - Street 1:4311 SALISBURY ROAD
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32216
Practice Address - Country:US
Practice Address - Phone:904-332-4316
Practice Address - Fax:904-332-4339
Is Sole Proprietor?:No
Enumeration Date:2006-03-23
Last Update Date:2013-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP1663702363LF0000X, 207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL302869100Medicaid
FL302869100Medicaid
FLP38183Medicare ID - Type Unspecified