Provider Demographics
NPI:1093044463
Name:SMITH, PAMELA MICHELE (CRNA)
Entity Type:Individual
Prefix:
First Name:PAMELA
Middle Name:MICHELE
Last Name:SMITH
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:PAMELA
Other - Middle Name:MICHELE
Other - Last Name:LEWIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CRNA
Mailing Address - Street 1:PO BOX 37090
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21297-3090
Mailing Address - Country:US
Mailing Address - Phone:703-295-9360
Mailing Address - Fax:703-295-9369
Practice Address - Street 1:5818 HARBOUR VIEW BLVD
Practice Address - Street 2:SUITE 240
Practice Address - City:SUFFOLK
Practice Address - State:VA
Practice Address - Zip Code:23435-3315
Practice Address - Country:US
Practice Address - Phone:757-483-6100
Practice Address - Fax:703-295-9369
Is Sole Proprietor?:No
Enumeration Date:2009-12-15
Last Update Date:2012-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC237361163W00000X
VA0024169997367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8053790Medicaid