Provider Demographics
NPI:1093460420
Name:DRAYTON-BELL, PAMELA G
Entity Type:Individual
Prefix:
First Name:PAMELA
Middle Name:G
Last Name:DRAYTON-BELL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1302 HONEYTREE LN E
Mailing Address - Street 2:
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33801-6537
Mailing Address - Country:US
Mailing Address - Phone:863-899-0731
Mailing Address - Fax:
Practice Address - Street 1:7410 EASTVIEW PL
Practice Address - Street 2:
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33810-2106
Practice Address - Country:US
Practice Address - Phone:863-450-2168
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-15
Last Update Date:2022-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL10002088320900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL691220696Medicaid