Provider Demographics
NPI:1073679270
Name:MADDOX, PAMELA KAY (MSN-FNP)
Entity Type:Individual
Prefix:
First Name:PAMELA
Middle Name:KAY
Last Name:MADDOX
Suffix:
Gender:F
Credentials:MSN-FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1246 KANAWHA AVE
Mailing Address - Street 2:
Mailing Address - City:DUNBAR
Mailing Address - State:WV
Mailing Address - Zip Code:25064-3008
Mailing Address - Country:US
Mailing Address - Phone:304-389-0402
Mailing Address - Fax:
Practice Address - Street 1:1246 KANAWHA AVE
Practice Address - Street 2:
Practice Address - City:DUNBAR
Practice Address - State:WV
Practice Address - Zip Code:25064-3008
Practice Address - Country:US
Practice Address - Phone:304-389-0402
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-29
Last Update Date:2021-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV47383363LW0102X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3810006267Medicaid
WV3810024049OtherGROUP MEDICAID
WVB441OtherGROUP MEDICARE
WV3810024049OtherGROUP MEDICAID