Provider Demographics
NPI:1043339070
Name:EDGAR WELLS, PAMELA K (OTR)
Entity Type:Individual
Prefix:
First Name:PAMELA
Middle Name:K
Last Name:EDGAR WELLS
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:PAMELA
Other - Middle Name:KAY
Other - Last Name:EDGAR
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OTR
Mailing Address - Street 1:5952 OLD PROVIDENCE RD
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28226-6808
Mailing Address - Country:US
Mailing Address - Phone:704-287-7365
Mailing Address - Fax:704-364-4232
Practice Address - Street 1:3315 SPRINGBANK LN
Practice Address - Street 2:SUITE 206
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28226-3197
Practice Address - Country:US
Practice Address - Phone:704-287-7365
Practice Address - Fax:704-341-2244
Is Sole Proprietor?:No
Enumeration Date:2007-03-29
Last Update Date:2007-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0960225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC12744OtherBCBS
NC7301422Medicaid